Month: March 2022

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Preparing for your first end-of-life conversation as a resident

By Jules Murtha

Key Takeaways

  • Some healthcare providers struggle to initiate and maintain end-of-life (EOL) conversations with patients due to lack of proper training.
  • Aspects to consider include determining who to include in the conversation, what your goal is, when and where to have it, and how you’ll structure the interaction.
  • General practitioners with experience in EOL conversations cite four important elements: preparation, finding a conversational entry point, modifying your communication to suit the individual, and inviting the family to participate if possible.

Engaging in end-of-life (EOL) conversations with patients requires careful, strategic communication on the part of the physician. For physicians and residents who lack experience covering the complex subject of death with their patients, EOL conversations can be difficult, according to a study published by the Annals of Palliative Medicine.[1]

Good physician communication, however, is central to patient satisfaction during palliative care. Residents can better prepare for EOL conversations by determining the logistics of the interaction beforehand, and tailoring their presentation to the patient’s preferred communication style.

First, focus on logistics

If you’ve yet to have your first EOL conversation in residency—or your first few—you might feel ill-equipped to start one. Even physicians who have established practices struggle to engage in such weighty interactions. Fortunately, there’s a list of questions you can answer prior to the discussion that may pave the way to meaningful results.

An AMA Journal of Ethics article explains the significance of addressing the logistical elements of an EOL conversation before starting one. [2]

These include the following:

Who? Clarify with your patient who exactly they’d like to have present for the conversation. Family members, while supportive, may disagree on treatment options or get swept up in intense emotions. It’s your responsibility as a physician to call everyone’s focus back to the patient. Patience will serve you well in EOL discussions, especially those that include family.

What? Determine what you’d like to accomplish with the conversation. Perhaps your goal is to provide updates on your patient’s prognosis, or deliver important news. On the other hand, maybe now’s the time to ask your patient what their goals of care are, or to relay that information to the family and other caregivers. You decide how much to share about the illness and its prognosis based on what your patient is ready to receive.

Where? Most often, EOL conversations take place at a patient’s bedside. This is largely due to their condition and lack of other space.

Having a quiet room free of interruptions is important for this kind of discussion. Sit near the patient rather than standing above them; this shows that you care and have time for them, and are not in a rush to leave.

When? Schedule EOL discussions when you have time to actively listen and be present for your patient. Be sure to clarify any misunderstandings, offer suggestions, and propose next steps. Try to steer clear of integrating EOL conversations into your routine rounds and office visits, as you might be too busy racing the clock to give your full attention.

How? Having a loose conversational structure may be helpful. Start by naming any goals you may have for the interaction while maintaining the flexibility your patient may require. Ask an open-ended question. Remember that your patient’s needs and ability to accept information are foremost. Listen first. This is likely to be a heavy moment for your patient, fraught with emotional upheaval that prevents them from taking in what you have to say.

“Silence can be golden in these conversations.”
— AMA Journal of Ethics

Taking cues from general practitioners

General practitioners who have had a lot of experience in palliative care conversations have developed a feel for them that can help guide residents in finding their own approach. These strategies, described in a study published by Family Practice, emphasize preparation, alongside three additional tactics to aid physicians in EOL interactions.[3]

Gauge readiness and choose an entry point

According to GPs participating in the study, successful EOL conversations are rooted in a strong patient-doctor relationship. Having already established good rapport and trust with a patient eases the EOL conversation, over and above preparing for it.

It’s important to gauge a patient’s readiness to enter into the EOL conversation. To do so accurately, you should consider the patient’s personality and psychological state.

Observe their demeanor, and pay close attention to any verbal and nonverbal cues they give you regarding their prognosis.

Once you feel you’ve got a good handle on your patient’s current state, focus on finding an appropriate conversational entry point.

There are different ways to do this, as the doctors told Family Practice. You can respond to patients’ inquiries about their goals of care, or implement EOL conversations routinely with patients who could benefit from them. For some patients, the physician might directly address their prognosis, whereas for others, it might be best to test the waters by asking indirect or hypothetical questions about plans for their future care.

Read your audience and involve the family

Two other tactics that GPs use to engage in fruitful EOL conversations are tailoring communication to the patient’s communication style and getting the family involved when it’s appropriate, as noted in Family Practice.

To better reach your patients, you may have to modify your communication style and approach the EOL discussion in increments, rather than all at once. Using a gentle approach for the patients for whom this is appropriate could mean saying something like “The chances of someone living with this for more than two years are very low.” For others, depending on the personalities of both physician and patient, and their relationship, a direct, honest approach may be the most fruitful.

Finally, the patient may choose to have family members in the room during EOL conversations. Some doctors find the presence of family to be valuable for information-sharing purposes and determining the right course of treatment for patients nearing their final days.

What this means for you

Residents who struggle with EOL conversations and  discussions about goals of care may sharpen their skills in a palliative care rotation. In the meantime, prepare for EOL conversations by answering the following: Who will be present? What is the goal? Where is the best place to initiate it, and how soon?

Think about how you can structure the conversation to best meet your patient’s needs. Once you enter into the conversation, adjust your communication to a style that’s most sensitive to your patient, whether this means taking a gentler, or more direct, approach. Finally, involve the patient’s family when you feel it’s appropriate.

Complete Article ↪HERE↩!

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How the Absence of a Funeral Makes Death So Much Harder For the Living

Olivia Claire Friedman on Trying to Mourn Without Ritual

Rippingille, Edward Villiers; The Funeral Procession of William Canynge (c.1399-1474), to St Mary Redcliffe, Bristol, 1474

By Olivia Clare Friedman

In January 2021, I lost one of my very favorite people. Frances was seventy years old when she died. Her death wasn’t COVID-related. I’d known her since I was twelve. She was in her thirties then. She was divorced—had been for years, her ex-husband lived in another state, I never met him. And she had no children. I was the closest thing to her child. I was her daughter, she said.

Because of the pandemic, her funeral was put off. I’d just turned in a draft of my novel Here Lies, set in a dystopian future in which the government cremates the bodies of the deceased and then keeps the ashes. A young woman named Alma tries to re-claim the ashes of her mother. All the while, Alma must find her way through grief and mourning.

Just after I’d finished the novel, Frances was gone. I found myself inside the cloud of grief, trying to sort through it and finding no answers. I became a mourner-in-waiting. For Frances, we had no funeral. Family members didn’t want to risk a gathering, and I knew, in pandemic times, this was the right approach. Frances wished to be cremated, and so she was. When the time is right, we’ll have a celebration of life, a friend of Frances’s said. Maybe something on a boat. We’ll scatter her ashes. Since then, we haven’t made plans.

My mourning feels suspended in time. Something inside me is holding its breath.

I found myself inside the cloud of grief, trying to sort through it and finding no answers.When I cried for Frances, I cried by myself. I didn’t want to upset my baby or my husband, so I shut the door to our bedroom and wept. But my husband understood. He lost his father to cancer ten years ago. He says he felt like his life broke in half. There was everything before his father’s death, and everything after.

Even though I’d closed the door, my baby could hear me crying. My husband said she asked for me, pointed to the door. Later, when I thought I was done crying, I’d go and do something else, like prepare for teaching or take care of laundry, and the grief would circle back, coming up all over again. That is the difficult part, when the grief returns without a warning. Grief that bubbles months later, years later—that’s the grief that lands a surprise blow.

My sadness has no order. It can be hard to see a trajectory, a way out, just as it has been hard to see a trajectory to the virus, a real sense of an ending. Of course, in writing, we try to find an arc, a shape to things. Right now, Frances’s death hasn’t had a shape. She was here, and she is gone, and there hasn’t been a funeral or ritual to mourn her.

In the middle of the pandemic, this was a heartshatteringly common story—deaths and no ritual to mourn. I wonder too about others who have felt relief. Not everyone wants a ritual for their grieving. Some won’t want to mourn at all, or they won’t want to go to a funeral, maybe because they were estranged from the deceased, or they don’t want to travel, or they’re too raw-hearted, or just ambivalent. There are those stories too.

My mourning feels suspended in time. Something inside me is holding its breath.The decision about what happens to our bodies after death is one of the most personal choices we make. Traditional burial, cremation, a green or natural burial…we choose. It’s a choice that might be rooted in family wishes, religious expectations, cultural traditions, personal preference, or all of these. Still, we choose. We can also not choose. Even the decision to choose—that decision is ours.

We already know that rituals of mourning are part of the heart of most cultures and traditions. I think about luxurious rituals, brimming with people and songs. I think of opulent funerals and horse-drawn carriages and the blasts of trumpets. I think of the Terracotta Army, a massive assembly of terracotta sculptures of thousands of soldiers, chariots, and horses buried in the tomb of Qin Shi Huang, the first Emperor of China. I think of the many sounds of New Orleans’ “funerals with music,” what were called jazz funerals, and second lines. I think of photos I’ve seen of massive funeral pyres. Of long processions of cars I’ve driven by on local roads, or images of funeral crowds overwhelming cathedrals, people pouring out of the doors.

There is also quiet mourning, silent mourning. During some periods in British culture, the length of mourning was expected to be nine months. Wearing all black, of course, visibly signaled your mourning state to everyone around you. Nine months—the period of gestation! And I think of Dickens’ Oliver Twist going to live with the undertaker. Oliver has “an expression of melancholy in his face,” the undertaker says, so he decides Oliver would make “a delightful mute,” staying silent and wearing all black, walking alongside the coffin at children’s funerals.

I think about solo mourning. Recently, I was discussing the subject of funeral rites with a friend, and he brought up Antigone. Antigone is the Greek mythological figure, the daughter of Oedipus, whose story concerns the burial of her brother. Because of the nature of her brother’s death, his burial is punishable by death, King Creon says. Even mourning him is punishable by death. But Antigone can’t abide this. She still buries her brother on her own.

The decision about what happens to our bodies after death is one of the most personal choices we make.Even with a ritual to mourn Frances, a part of me would always feel suspended, like I was holding something in. But a funeral, a celebration of life, can give mourning a location, its own spot on the map of grief.

Grieving can make you feel selfish and ridiculous and angsty and tangled. One loss summons previous loss. With Frances’ death, a string was pulled. My grief brought up past deaths. I thought of the deaths of my grandmothers, great and great-great, from years back. One died of cancer, another grandmother died of natural causes. All of the grieving gets knotted together.

Frances’s obituary was longer than other obituaries I’ve read. The act of reading it was a kind of ritual, because it captured her so well, the experience of knowing her. She loved animals close to the way she loved people. She was one of the most generous souls you ever met, and she was also very candid and keen. She lived with an illness almost all her life. She lost her parents at a young age. At the end of the obituary were the names of loved ones, family and friends, in Frances’s life. And seeing that, everyone’s names together, made me feel like we were all standing there, physically somehow, in print but side by side. In ink—and I do believe in the power of ink—we had a kind of ritual mourning for Frances.

I have my own rituals to mourn her. They’re simple, seemingly small, but to me they’re not small at all. I look out the window more than I used to. I look at the sky more than I used to. Are these rituals? Yes, I’ll call them that. And if I wanted to, I know I could have my own made-up ritual. I could light a candle and sing. I’m not sure what the words would be. My crying too is mourning, a ritual of mourning. Going outside in my yard by myself to cry or just to think alone—yes, I’m coming to understand, all this is a ritual too.

A funeral, a celebration of life, can give mourning a location, its own spot on the map of grief.In February, one month after Frances’s death, a small gray cat started coming to our door. This was significant—Frances had adopted many cats, maybe thirty-something. She stopped counting; she was embarrassed; her house was overrun. As soon as you walked in through her front door, you’d smell cat pee. She had cat beds in rows on top of her own bed. One time I saw a tomcat pee on an electric socket, and the whole thing started sparking.

So this little striped gray cat kept coming around our door, and of course my husband and I fed her, and of course she wouldn’t leave.

I waited to name her, because I knew when I did, that’d be it. And anyway, when I did start to think of names, it was torturous to find the right one. How about Lady Grey? “No, not that,” my British mother-in-law said. Other ideas were the names I’d wished I had when I was a kid—Fiona, Michelle, Serena. I thought about her face, her expression and eyes. I’d try out one name, and then I’d scratch that and decide to start over. We left her nameless for months. Then one day, I went all in. I finally decided on a name.

Annie is wild and scrappy. Her tail is three-quarters gone. She leaves mushed-up mice and lizards on our welcome mat, dead voles with pink claws in the air. These are her gifts. She’s been with us for months. We’re used to her now, but I’m not used to Frances gone, and sometimes I have to remind myself: She’s not here. I don’t know if we’ll gather with her ashes, but here comes the gray cat when I open the front door, ready for breakfast. Here she is—rolling in dirt, sniffing the air.

Complete Article ↪HERE↩!

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Doctor describes what it’s like to provide medical assistance in dying in new book

After more than 20 years delivering babies into the world, Dr. Stefanie Green, seen in an undated handout photo, decided to specialize in delivering suffering people out of it. Green has now written a book, “This is Assisted Dying: A Doctor’s Story of Empowering Patients at the End of Life,” describing the first year of her new practice.

By Joan Bryden

After more than 20 years delivering babies into the world, Dr. Stefanie Green decided to specialize in delivering suffering people out of it.

She was among the first Canadian physicians to offer medical assistance in dying, known as MAID, once it became legal in this country in 2016.

Green has now written a book, “This is Assisted Dying: A Doctor’s Story of Empowering Patients at the End of Life,” describing the first year of her new practice.

She provides heartbreaking details of patients she helped, and the ones she could not because of the restrictive nature of the new law, which limited the procedure to people whose natural deaths were “reasonably foreseeable.”

She describes the gratitude of grieving family members but also the man who accused her of murdering his aunt. The loving last words exchanged between a husband and wife, lying naked together in bed, and the patient whose parting words to her good-for-nothing grandson were “clean up your crap.”

Green also describes in painstaking detail the care that goes into assessing a patient’s eligibility for an assisted death and the series of lethal injections designed to gently ease a patient into sleep, then a deep coma before the heart finally stops.

The book, Green said in an interview, was partly an attempt to stimulate discussion about the end of life, a topic most people are afraid to talk about. But it was also therapeutic for her.

“The real raw truth is that, as soon as I started doing this work, I was kind of overwhelmed with the incredible experiences I was having … The work itself and the intimate relationships that I was kind of thrown into right away and the interactions I saw between people and their families were just extraordinary,” said Green, who heads the Canadian Association of MAID Assessors and Providers.

“At some point I decided I wish I could tell someone what’s happening, what I’m doing, what I’m seeing, what it feels like, what it looks like, how it works, you know, dispel those myths … It’s almost like I needed to tell someone.”

In an odd way, Green said her work as a maternity doctor was “a good fit” with providing medical assistance in dying, dealing with intense emotions and the family dynamics attending both the happy and unhappy events. Among family and close associates, she refers to assisted deaths as “deliveries.”

Indeed, she said helping to end people’s suffering has been the most rewarding experience of her career — although initially that was a sentiment she felt she had to keep to herself.

“What I was feeling was gratification that I was in a position as a clinician — as a person — to offer this assistance. But it occurred to me that I probably shouldn’t tell anyone,” she writes in the book.

“What would they think? ‘I helped someone to die today and I feel really great about it.’ I might be seen as a psychopath.”

But for Green, the experience was “profound” and a “privilege” to help people in need. She recounts in the book how “the sense of relief was palpable” when she told someone they were eligible for an assisted death.

“Once my patients were no longer fearful of how they might die, they focused intently on living and allowed themselves to more fully embrace the life they had left. MAID, in this way, was less about dying and more about how people wanted to live.”

Six years on, there are still relatively few Canadian doctors and nurse practitioners who assess eligibility or provide assisted deaths — about 1,300, Green estimates.

In part, she thinks that’s because of the initial ambiguity of the new law and confusion over how the term “reasonably foreseeable death” should be interpreted. She admits in the book that fear of interpreting the term too broadly — and potentially facing 14 years in prison if she did — led to agonizing decisions to turn down some desperate patients, about whom she still feels guilty.

The foreseeable death requirement was dropped from the law earlier this year, in response to a Quebec court ruling that struck it down as unconstitutional. Intolerably suffering people who are not near the natural end of their lives are now eligible for assisted deaths, although they face more stringent eligibility rules than those who are near death.

But Green said there’s been no rush of Canadians clamouring to take advantage of the expanded access. Moreover, she said MAID providers have been “very, very cautious” about applying the expanded eligibility criteria, with some refusing to provide the procedure for anyone who is not near death because the eligibility rules are “too complex and they can’t commit the time to it,” particularly during a pandemic.

It’s about to get more complicated too. Among the amendments to the law passed last March was one that will lift the ban on assisted deaths for people suffering solely from mental illnesses in 2023. That will likely require a whole new set of safeguards and eligibility rules for that group of patients.

And a joint parliamentary committee must still grapple with whether to expand access to include mature minors and whether to allow advance requests for assisted dying from people who fear losing mental capacity due to dementia or other competence-eroding conditions.

The latter is popular among Canadians but is particularly complicated, in Green’s view. In the book, she notes that people often say they’d like to be able to spell out in advance the conditions under which they would want an assisted death — for instance, when they no longer recognize family members.

But she asks, would the condition be met the first time a patient fails to recognize a family member? “The second time? When it’s consistent? Over how long a time period?”

She also questioned: Who decides when the condition has been met? And what if that patient seems to be living comfortably in a specialized care facility, getting enjoyment out of small things even if they are no longer the person they once were?

“Who’s suffering should we take into account? The person who was or the person who now is? It’s simply not so simple.”

Complete Article ↪HERE↩!

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I look at death every day – let’s change the way we talk about it

By Adesola Mojo

As a forensic pathologist, the dead of all ages, shapes and sizes have been the focus of my career. Numerous times a day, for the past 40 years, I have looked closely and directly at death, knowing that, for many – probably most – of the people I examine, the start of their final day had been completely normal. Death had come swiftly and unexpectedly. So, as I dress each morning, I often wonder where I will be at the end of my day. At home? Or in a mortuary, being slid into a fridge on a shiny tray?

In medical circles, we had been expecting a global pandemic for several decades. The HIV/Aids pandemic of the 80s was a sombre milestone, resulting in about 36 million deaths worldwide, but I never anticipated that the first pandemic of the 21st century would develop from a virus in China. I had expected it to come from a lethal reorganisation of the DNA of the influenza virus – as happened in 1918, when “Spanish” flu killed at least 50 million people worldwide, and in the subsequent, less lethal, influenza pandemics: 2 million died in the 1957 flu pandemic and 1 million each in 1968 and 1977. The last notable flu pandemic was swine flu, in 2009, which resulted in about 500,000 deaths. A serious influenza pandemic is about 50 years overdue.

Death had become a subject to be avoided or glossed over. Our lack of experience often meant it felt overwhelming

I know that I am unusual in having had such a longstanding personal insight into death and the fundamentally precarious nature of our lives. Many of us have never seen a dead body, even of a close relative. In our westernised, urban society, the tradition of paying your respects to the body in an open coffin in the parlour is now rare. This offered the opportunity to recognise the normality of death: to look it in the face; to consider your responses; to remember your own impermanence

By the start of this century, it seemed to me that death had become a subject generally to be avoided, glossed over, obfuscated and (if at all possible) simply ignored, at least until one was faced with it personally. Now, the lack of this experience often means it feels overwhelming.

Before Covid, I noticed how our language was becoming increasingly euphemistic. The noun is “death”, the verb is “die”, but these words were seldom heard. Dying had become “passing” – and the focus was usually on “easing that passing”, to sanitise and smooth it and manage death in a way that diverted distress. I felt I was seeing a significant disconnect develop between the profound, human process of grieving, with its incumbent pain, stress and sadness, and the emollient aims of the death industry. It was a disconnect that was welcomed by so many.

The pandemic challenged this approach in almost every respect. Suddenly, death and the consequences of death were the focus, day after day, of every news report. The facts were raw and painful, the words stark. The noun was “death”, the verb was “die”. These people had not “passed”. Covid, I hate your harvest, but I thank you for rewilding such endangered language.

As the pandemic continued, interviews with families became the modern equivalent of the wake beside the coffin in the parlour. Where once there was little or no desire to see the body after death, now the denial of contact, at the end of life and afterwards, was traumatizing.

I hope one positive to come out of our new reality is a change in society’s approach to death. It is still too early to tell – and perhaps I never will be able to tell, since I am inside the taboo, looking out. But, from my perspective, I would say that a new willingness to engage with death would be a healthy change.

I have been lucky. Few of my close family have contracted Covid; none have died from it or even been hospitalized. However, during the course of the pandemic, three of my friends have died: two from natural disease – one suddenly, one slowly and painfully – and one from an accident. Covid has killed many, but, even in the depths of a pandemic, I was reminded that people continue to die of other causes – and that these causes also kill millions.

Let us face up to the inescapable fact that humans die. Until then, life is for living.

Complete Article ↪HERE↩!

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Grief, like death, is still taboo for many of us. But is that starting to change?

There are often no words for what we endure. Yet after the pandemic, more people are trying to find a language of loss

By

Widow is an awful word. It conjures up such drab and lonely images; and besides, it defines a woman by what she has lost and what she no longer is. But at least there is a word for having lost your husband. For the other heart-stopping losses that come to many in midlife, and some even earlier – the death of your parents, or of a sibling, or a child, or perhaps a best friend – there isn’t even a word. Yet these are life stages in their own right too, and deserving of closer understanding. For some reason, which may or may not be connected to the raw and unpeeled state of our emotions after a pandemic, a small window now seems to be opening on to an underexplored world.

The writer Clover Stroud’s The Red of My Blood, a memoir about trying to make sense of the death of her 46-year-old sister, Nell, from cancer, was published recently to a chorus of recognition and relief from some bereaved readers. After the funeral and the flurry of condolence letters, and the awkwardness of people just not knowing what to stay, there is still the long haul ahead of reconstructing a good life without someone who used to be central to it. And that’s what this book is about. Clover is a working mother of five: she might be dazed with grief but there is still pasta to be cooked, school runs to be done. In the spaces in between, however, she is constantly puzzling over the seeming impossibility of Nell being gone. How can she simply stop existing? The book revolves around Clover’s constant search for her sister, looking for her in photographs and in places they went as children and in the last things she touched when she was still alive. When you lose someone you love, they are suddenly everywhere but nowhere. Decades on, I still remember that irrational lurch of recognition at the face in the crowd that surely has to be them – except, of course, when you get closer it isn’t, and can’t ever be again.

More pragmatic but no less quietly moving was the interview Harriet Harman gave last week to Sky News’s Beth Rigby about coming to terms with the loss of Jack Dromey, her husband of 47 years. They were one of the most devoted couples at Westminster, and Dromey’s unstinting support for his wife powered her through the most gruelling stages of her career, juggling small children with working in a parliament still deeply hostile to women. But intensely as she will have felt the loss, as she points out she might have decades left to live without him – and she is trying to figure out how widowhood can become a different chapter in life, not the end of it. “People say, ‘Oh now that you’re on your own …’ but – I’m not with Jack any more, but I’m not on my own. I’ve got my children; I’ve got my friends; I’ve got my work colleagues. And I don’t agree with the notion that’s somehow out there that when you’re a widow your life is over and that somehow you’re a lesser person,” she told Rigby.

For all the grief and loss, she said, “people are themselves in widowhood just as they are themselves in the rest of their life”. As women they are very different characters, but both Stroud and Harman are grappling with essentially the same thing: how to find life again in the midst of death, without pushing away or denying the reality of what has happened.

It’s a stage most of us would perhaps rather not think about, even though grief comes to almost everyone who loves someone in the end. But if death itself is the last taboo, then the final frontier to be breached is what comes after; the slow, difficult process of learning to live with that loss, which takes much longer than the impatient outside world is often willing to accept. Time heals, everyone says, and there is a sort of truth in that. The wound doesn’t go away but it does change, slowly solidifying into scar tissue that will always be there. The beauty of Clover’s book is that there is no neat ending, just as in death there so often isn’t. What’s left, however messy, is the search for a different way of living.

Complete Article ↪HERE↩!

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Human-Shaped Sarcophagus in Ancient Tombs Uncovered in Notre-Dame

A picture taken on April 16, 2019 shows an interior view of the Notre-Dame Cathedral in Paris in the aftermath of a fire that devastated the cathedral. – French investigators probing the devastating blaze at Notre-Dame Cathedral on April 15, 2019, questioned workers who were renovating the monument on April 16, as hundreds of millions of euros were pledged to restore the historic masterpiece. As firefighters put out the last smouldering embers, a host of French billionaires and companies stepped forward with offers of cash worth around 600 million euros ($680 million) to remake the iconic structure.

By Miguel Brown

After the Notre Dame Cathedral in Paris burned in 2019, archaeologists have uncovered several tombs from the 14th century in the now “burial site” of “remarkable scientific quality”.

Along with the tombs unearthed was a human-shaped sarcophagus made of lead, ScienceAlert reported. According to the culture ministry, the newly revealed tombs beneath Notre-dame were found during the preparatory and general planning of the restoration works for rebuilding the ancient church

The ministry announced on Monday that the two major discoveries unearthed under the nave and the polychrome fragments of the original 13th-century rood screen of Notre-Dame, will make it possible to document the monument’s history.

The coffin, which was thought to have been made for a senior dignitary in the 1300s, as well as the tombs and some painted sculptures were found just under the current paving level of the cathedral.

During an archaeological visit

On Tuesday, the Agence France-Presse (AFP) and archaeologists visited and delicately excavated sculptures emerging from the ground, including a pair of carved hands, bust of a bearded man, and some sculpted vegetables, with traces of paint.

The team inserted a mini endoscopic camera to peek inside the sarcophagus warped by earth and stones and caught a glimpse of “pieces of fabric, hair and above all a pillow of leaves on top of the head, a well-known phenomenon when religious leaders were buried,” said lead archaeologist Christophe Besnier. “The fact that these plant elements are still inside means the body is in a very good state of conservation,” he noted.

Dominique Garcia of the National Institute of Archaeological Research added that this discovery shed better light on funeral practices in the Middle Ages.

These discoveries happened to be found when reconstruction teams prepared to install huge scaffolding to rebuild the spire, and needed to check the stability of the ground.

A completely preserved anthropomorphic lead sarcophagus

The fully preserved lead sarcophagus was unearthed among the graves in the western part of the excavated site. In the first analysis, archaeologists dated the burial at the latest from the 14th century. Plant remains under the head of the deceased were also identified aside from the hair, fragments of textiles, and organic matter.

The sarcophagus was lying among an underground heating system’s brick pipes from the 19th century. While this find had archaeologists working, they have limited time to do so. The archaeological excavation is just the first step in a study phase and must be completed on the ground on March 25, before the reconstruction project resumes. As for the lead sarcophagus’ removal, it will be carried out in the coming days.

Meanwhile, the sculpted fragments attributed to the 13th century rood screen may be collaborated with the polychromy center of the Historical Monuments Research Laboratory (LRMH), or with the Sculpture Department of the Louvre Museum.

Nonetheless, all the discoveries and every fragment were considered “exceptional interest” for understanding the history of Notre-Dame de Paris – which is proposed to be reopened in 2024, according to CNN.

Complete Article ↪HERE↩!

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After death – what?

Most modern funeral practices don’t do much good for the planet. Manuela Callari takes a look at what happens, scientifically speaking, if nature is allowed to take its course after we die, and emerging options that soften our carbon footprint after our exit.

By MANUELA CALLARI

Overlooking the coastal sandstone cliffs south of Sydney’s CBD, gravestones in Waverley Cemetery stand like sentinels, aligned like a military parade. A Yulan magnolia grows out of the grave of a post World War II Italian migrant, at rest since 7 May 1977. It’s as if it is drawing its sustenance from the deceased.

Life depends on death – a circle that has been going on forever. Saplings grow out of rotting trees, and marine carcasses provide a bounty of nutrients for deep water organisms.

When creatures die, they decompose and become the nutrients that other life forms need to flourish. But most humans end up embalmed and buried, or cremated. Are the rituals we have created messing with this cycle of life?

Some think so. “Green death” trends have emerged in the funeral industry to respond to people’s growing concerns around the ecological burden of traditional burial practices.

The science of human decomposition

First, what happens when a body decomposes out in the open? A little warning here is due: this is not a story for the squeamish. When you die, your heart no longer pumps blood through your veins. Gravity draws the blood towards the ground, where it settles. Your lungs stop functioning, which means you’re not breathing in oxygen or expelling carbon dioxide. As carbon dioxide builds up and dissolves in the pooling blood, it begins to form carbonic acid, which dissociates into bicarbonate and hydrogen ions, making the blood acidic.

Simultaneously, enzymes involved in your cells’ metabolism throughout life begin to digest the cells’ membrane, which, combined with a decreased blood pH, causes cells to rupture and spill out their guts. “Everything starts to break apart,” says Dr Maiken Ueland, a researcher at the Centre for Forensic Science and the deputy director of the Australian Facility for Taphonomic Experimental Research (AFTER) at the University of Technology Sydney.

When your cells begin to crumble, they release nutrients that the human microbiome – all the bacteria, fungi and viruses and other microbiota living in you – love to gobble up, literally eating your body from inside out.

Your microbiome helps digest food and keeps your immune system in good shape throughout life. But when you’re dead, your immune system shuts down, and all of a sudden, trillions of microorganisms have free rein.

The microbiota break down carbohydrates, proteins and lipids, producing liquids and volatile organic compounds as byproducts. These build up inside your abdomen and make you look bloated. After three days of decomposition, these compounds release, causing a distinctive “death” smell. Carbon dioxide, methane, and ammonia gasses are among the contributors. Hydrogen sulphide, also present in farts when you’re alive, plays a critical role. But putrescine and cadaverine, which are formed from the breakdown of amino acids, are the biggest culprits.

Ueland, who studies forensic taphonomy – the process of corpse decomposition – says the gasses emitted from the body as it breaks down attract more fungi, bacteria, worms, insects and scavengers to the banquet. A decomposing body creates a remarkably complex ecosystem, which taphonomers call the necrobiome.

Blowflies are generally early comers. They start to lay eggs from which maggots hatch within 24 hours. One blowfly can lay about 250 eggs, so if a few hundred blowflies lay eggs, there are soon tens of thousands of hungry maggots crawling on your body, ready to contribute to the decomposition process. Larvae consume the soft tissue first, says Ueland. Then the skin falls apart, and all that is left is your skeleton, which will continue to break down for decades.

As the feast goes on, more nutrients are released into the surrounding environment. For every kilogram of dry body mass, a human body naturally decomposing will eventually release 32g of nitrogen, 10g of phosphorus, 4g of potassium, and 1g of magnesium. So an average 70kg live human body, which consists of 50–75% of dry body mass, would release roughly 1,400g of nitrogen, 434g of phosphorus, 174g of potassium and 43g of magnesium after death.

Taphonomers call this puddle of nutrients around a body “the cadaver decomposition island”. Initially, some of the vegetation in this island dies off, possibly because of nitrogen toxicity. But as the nutrients are further digested by bacteria within the island they act as fertilisers, transforming the island into a vegetation oasis.

After death what

Death 1.0: the industrial age

In a typical burial, the body is embalmed and put in a coffin made of oak or elm. The wooden capsule is buried about two metres underground, possibly under a slab of concrete. Formaldehyde is often used as an embalming fluid. It bonds proteins and DNA in the cells together so tightly that the microbiome can’t break it down, preventing tissue from decomposing for decades.

Even if a body isn’t embalmed, the coffin in which it lies hinders the natural decomposition process, and the nutrients released are not easily accessible to the microorganisms and scavengers in the soil.

If you’re not keen on burial, you can always choose to be cremated. Since the 1950s, cremation has become more popular than burial, with about 70% of Australians opting for it. But cremation, too, cuts the circle of life and death short. It transforms a body into mainly three things: ash, water vapour and a lot of carbon dioxide. Not only will cremated bodies not fertilise any vegetation oases, burning them up is far from sustainable.

Aquamation is the fire-free alternative to cremation. All that’s left is a tea-like solution that’s good for plants

According to the Department of the Environment and Energy, a modern cremator uses the equivalent of 40 litres of petrol for an average body. An older crematorium furnace can consume up to twice that amount of fuel.

Cremating a dead body releases about 50kg of carbon dioxide and a bunch of toxins into the atmosphere. And the carbon footprint doesn’t end at the crematorium door.

“What about the 100 people driving to the crematorium, then driving back to Uncle Bob’s house to have a barbecue?” says Kevin Hartley, founder and director of Earth Funeral. “And what about all the catering and all the energy and bits that go into it?”

Hartley estimates that at a typical, small-size cremation and funeral, the event can release up to one tonne of carbon dioxide – the equivalent of driving a petrol car for six months. Fifty trees have to grow for one year to capture just one tonne of carbon dioxide emissions.

Death 2.0: the eco-age

An interest in pared-down, eco-friendly, end-of-life options has grown, ranging from biodegradable pods that turn a body into a tree, to mushroom burial suits that devour dead tissues.

“There’s a whole suite of alternative technologies in this space,” says Dr Hannah Gould, a cultural anthropologist with the DeathTech Research Team at the University of Melbourne. “But alkaline hydrolysis and natural organic reduction are the major alternatives that have legs.”

Alkaline hydrolysis, also known by the catchier name of “aquamation”, is the fire-free alternative to cremation. It produces less than 10% of the carbon emissions of traditional cremation, doesn’t release toxins, and generates nutrient-rich water.

After death what
Give and take: Eco-friendly after death practises that give back are the subject of many start-ups. The Capsula Mundi, above, is an Italian-designed biodegradable casket above which you can plant, and nourish, a young tree. Memory Gardens, such as this one in Le Bono, France, offer the option of depositing ashes under different trees in a headstone-free green space.

The body is placed in a pressure vessel filled with an alkaline water solution of potassium hydroxide or sodium hydroxide or a combination of both, with a pH of 14. The solution is stirred and heated to about 160°C at high pressure to prevent boiling.

In a few hours, the body breaks down into its chemical components. All that’s left is a tea-like solution that is very good for plants, so family can take home the sediment of minerals for scattering.

“The environmental footprint of alkaline hydrolysis is much less than cremation and much, much, less than conventional burial in a graveyard,” says Professor Michael Arnold, a historian and philosopher with the DeathTech Research Team.

According to a report by the Netherlands Organisation for Applied Scientific Research (TNO), the estimated environmental cost for disposal of the dead is about $102 for a burial, $77 for cremation, and $4.15 for alkaline hydrolysis. “It’s a huge factor,” says Arnold.

Aquamation is legal in Australia but not widely available. There are only a handful of companies that offer the service, and, Arnold says, the practice remains little known by most. It was recently in the spotlight after the death of South African archbishop Desmond Tutu, who requested his remains be aquamated. Arnold hopes Tutu’s choice will increase the practice’s popularity.

The other alternative is natural organic reduction, or human composting. The body is placed into a vessel with a mix of soil, wood chips, straw and alfalfa. Microbial activity stimulates decomposition. Within about four weeks, the result is around 760 litres of humus. Family members are welcome to keep some of it; the rest is used as a fertiliser. The world’s first human composting company opened its doors in Seattle, US, at the end of 2020 and has since expanded to four states, but human composting isn’t yet legal in Australia.

The regulatory approval path of a new way to dispose of corpses is tedious. But appealing to the mass market remains the biggest challenge – eco-friendly body disposal is still a niche market.

“People who might want to pick these options tend to be those who are pretty concerned about the environment, who are into sustainability, alternative lifestyle, are a bit hippie,” says Gould. “But there is also a growing cultural desire to return nutrients to the earth.”

Arnold agrees. “A lot of people think that the body is something to be disposed of without much fuss, and cremation is appealing for that reason,” he says. “A smaller group of people think of the body as a resource rather than a waste – a resource that can and should be utilised by other living beings.”

In recent years, natural burial grounds have gained some popularity. Here, the body is buried without embalming in the topsoil, in a softwood or cardboard coffin or a shroud. Usually, there is no gravestone or headstone. Only about 2% of people opt for a natural burial.

Restoration burial grounds

Hartley had worked in funeral services for 15 years when someone asked what his plans were for his body after death. “Being reasonably young, I hadn’t really thought about it,” he says.

It was then that he began to ponder the environmental impact of the furnace he
had operated for so many years, and began to question whether that was indeed what he wanted his final act to be.

Hartley began to contemplate taking natural burial to the next level. “Restoration burial grounds is the term that we favour,” he says.

His not-for-profit organisation plans to convert pieces of distressed land, such as overused farmland on the edges of cities, to burial grounds that offset the cost of burial by “multiple times”.

The bodies will nourish and fertilise the barren land, restoring the native Australian bush. That, in turn, will attract native wildlife and, eventually, the land will be managed like a national park.

Regular natural burial grounds might offset the carbon cost of a burial, but being carbon neutral is no longer enough, Hartley says.

“We put the Earth bank account into deficit,” he says. “We are way overdrawn. We want to put back into the planet.

“Death is part of life. Everything is cyclic. We’re interested in the restoration of the nexus between death and life for people and have a genuine return to the earth.”

It’s a plan that might revolutionise the look of Australian cemeteries – rows of gravestones giving way to Australian native forests buzzing with wildlife.

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