Month: December 2023

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Who gets to decide when you die?

— States consider medical aid in dying

More than a dozen states introduced bills to legalize the practice in 2023, which observers say can improve end-of-life systems and processes for families and health care providers.

by Kaitlyn Levinson

Death is a taboo topic, especially when someone dies of their own choosing. But there are growing numbers of people suffering with incurable illness who wish to die peacefully, and recently, more states are turning to aid in dying programs so individuals can have more end-of-life health care options.

Last year, Washington saw the highest number of patients—446—die under the state’s medical aid in dying program, up from 387 in 2021.

An increase in the number of people interested in and requesting medication to die indicates states’ need to reevaluate their approach to end-of-life programs, said Arthur Caplan, director of the Division of Medical Ethics at New York University’s Grossman School of Medicine’s Department of Population Health.

Medical aid in dying programs offer a terminally ill adult patient the option to end their life with a prescribed medication if their health conditions severely impact their quality of life, such as living with chronic or unbearable pain and discomfort. Research shows that cancer patients are the most common users of medical aid in dying.

Medical aid in dying is legal in 10 states—California, Colorado, Hawaii, Maine, Montana, New Jersey, New Mexico, Oregon, Vermont and Washington—and the District of Columbia. All states require patients to be more than 18 years old and show no signs that a mental health disorder or intellectual disability could impact their end-of-life decision-making.

New Mexico was the latest state to authorize medical aid in dying in 2021. The new law requires that eligible adult patients must have a prognosis that their illness will result in death within six months, and they must be evaluated by a mental health professional who can assess their mental capacity to pursue medical aid in dying.

As policymakers and the public grow older, states’ interest in legalizing the practice will continue gaining momentum, Caplan said. The number of adults 65 and older, for instance, is projected to swell to 95 million individuals, or 23% of the whole U.S. population, by 2060.

This year, at least 17 states have introduced bills to legalize medical aid in dying, including Florida, Indiana and Maryland, where policymakers and advocates believe the bill will finally pass in 2024 after years of trying.

And in states where the procedure is already legal, policymakers continue to expand access to medical life-ending services. Oregon and Vermont, for instance, eliminated in-state residency requirements for patients seeking medical help with dying. Vermont also repealed a requirement for health care providers to wait 48 hours before writing a prescription for a patient requesting aid in dying.

Hawaii and Washington now allow advanced practice registered nurses to prescribe lethal medications, with the latter extending permission for physician assistants, as well.

While opponents claim medical aid in dying could open up the chance for health care providers or insurers to coerce patients into using the service to increase profits, Caplan said there is little evidence to suggest that happens in states where it is authorized.

Data also shows that the number of patients who do seek medical aid in dying is miniscule. In Oregon, for example, the percentage of patients who used the service in 2022 accounted for less than 0.6% of total deaths in the state, according to a report by the Oregon Health Authority. And of the 432 patients who received end-of-life prescriptions, 84 did not take the medication or later died of other causes.

Oregon was the first state to legalize medical aid in dying in 1994 with its Death with Dignity Act. But research suggests the state’s ground-breaking law has also resulted in more careful evaluation of end-of-life options and efforts to reduce barriers to hospice care.

Medical aid in dying laws can allow medical practitioners to give patients more control over their health care to alleviate the stress and trauma associated with death, said Kim Callinan, president and CEO of Compassion & Choices, a nonprofit advocacy group for patient autonomy of end-of-life planning.

The one thing guaranteed in life is dying, she said. And when policymakers, patients and advocates actively acknowledge that, they can work to improve end-of-life systems and processes.

Complete Article ↪HERE↩!

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Embracing life’s purpose in the face of inevitable death

“I cannot escape death, but at least I can escape the fear of it.”
– Epictetus

By Michael Brant-Zawadzki, MD

I wish more people knew that quote during the pandemic. I write this on November 1st, celebrated as Dia de Muertos or “Day of the Dead.” Epictetus and the other Stoics knew that death is inevitable, that life can change in an instant, and viewed it as a reminder to live each day purposefully and virtuously. In a world where meaningless death is a daily fact, only the individual can define meaning in their own lives.

This introduction is not meant to be morose but rather meant to explore the dilemmas in health care at the end of life. One of my colleagues took a phone call that I overheard. It was from the nursing home where his 88-year-old demented mother was housed, calling to say they were taking her to the emergency room due to a change in mental status. “Stop,” he shouted. “My mother has a do not resuscitate health care directive.” The conversation became an argument between the facility’s risk-averse nurse manager and him. The paramedics arrived, the nursing home protocol directed them to take her to the ER, and that was that. The ER soon called; my colleague’s mother was in septic shock, in renal failure due to a kidney infection, and they were starting her on IV antibiotics, and planning dialysis. The doctors were following their script, one based on best evidence-based care. The son anguished in his reminding them of his mom’s end-of-life directive, particularly because his sister, now in the loop, wanted to do “everything we can” if death was not a certainty.

But it is, as reluctant as we all are to acknowledge. Most frontline doctors won’t argue with a family member who reverses the directive in a moment of grief, panic, or guilt. Given their training, these acute care specialists are not willing participants in a “death panel.” The doctors’ skill set and enthusiasm also influence the approach. Highly skilled physicians – expertly trained and confident in their technical talents – are enthusiastic and passionate about what they do and want to do it. This is why advanced hospitals, like ours, have a palliative care team led by a physician, a trained social worker, with an ethics panel to help families and doctors in the throes of such life-wrenching decisions.

Economics plays a role. The amount of health care dollars spent in the U.S., 4.3 trillion dollars or 19 percet of GDP, includes 1.2 trillion spent in the last months of life. That 1.2 trillion is over four times as much as England spends for all health care annually (on a per-patient basis, England spends less than half as much as the US). In England, many procedures, including dialysis, are restricted by the National Health Service, based on utilitarian principles that consider quality of life versus cost. In the US, a fee-for-service payment system financially rewards physicians for each procedure: Hospitals are paid a per diem fee based on the admission diagnosis. This “per click” payment model influences decisions by both parties, consciously or not. Yet many providers and most families do not consider health care expenses when the moment comes to do “everything we can” in the last stages of life. Switching an in-patient to hospice care can improve a hospital’s “pay for performance” mortality scorecard.

The American College of Physicians previously issued guidelines that emphasize each physician’s duty to provide “parsimonious care”; that is, to “practice effective and efficient health care, and to use health care resources responsibly.” Their president at the time stated: “We also have to realize that [we must think] about how resources are used in an overall sense [or] there won’t be enough health care dollars for our individual patients. So while concentrating on our individual patients and what they need, we also need to think on this bigger level both for their benefit and for the well-being of the community at large.” My italicized emphasis brings to mind F. Scott Fitzgerald’s oft-quoted definition of a first-rate intelligence: The ability to hold two opposed ideas in the mind at the same time and still retain the ability to function.

Death is not an entity but a rumination: a tornado of thoughts, fears, visions, and emotions. Only humans see what can and – in the case of death – will be. Not all embrace the introduction, yet it is that sad certainty that introduces order, purpose, and increasing urgency into the human contract. The intensity of a loved one’s passing, or a pandemic, brings it to the forefront of the mind.

Or, as Camus put it in his famous book The Plague: “Plagues are infrequent but constant and they do not alter the conditions of mankind (everybody dies) but rather concentrate our misfortunes into moments where everyone thinks for a change that mortality is afoot.” The Stoics remind us daily that “mortality is afoot” to start each morning with a renewed passion for life.

Complete Article ↪HERE↩!

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Common Funeral Flower Etiquette Questions

When tragedy strikes and a life comes to its close, the world slows for a moment. Condolence flowers stand as a testament to that pause, a way of expressing our love, respect, and sympathy for the departed. They capture the transient beauty of life, the memories that remain behind, and the universal fragility we all share. This age-old gesture has its own unique tapestry of traditions and etiquettes. Let’s explore this further by weaving through uncommon perspectives.

The Tale of Two Cultures: East Meets West in Flower Etiquette

In the West, chrysanthemums, carnations, and roses are often presented as tokens of respect. Their colors, especially white and light shades, are symbolic of peace, purity, and remembrance. However, traverse to the East, particularly in countries like Japan, and chrysanthemums take on a more solemn note, specifically tied to death and are exclusively used for funerals.

Likewise, in some parts of Asia, the color white is deeply associated with mourning, whereas in the West, white flowers can symbolize innocence and purity. This brings to light the vast mosaic of cultural beliefs and practices associated with funeral flowers.

Beyond Petals: The Silent Language of Flowers

Each flower speaks a silent language, and the Victorians were adept at reading these floral messages. In a time when words of emotion were restrained, flowers did the speaking. For instance, a lily conveyed the message, “my thoughts are with you”, while forget-me-nots whispered of memories and remembrance.

Considering this, sending flowers becomes more than just a gesture. It becomes a silent conversation, a way to communicate grief, hope, and everlasting love without uttering a single word.

Exceptions in Elegy: When Flowers Might Not Speak Right

While flowers are accepted and appreciated in most cultures and religions, it is important to tread with care and respect. As mentioned, those of the Jewish faith might prefer not to receive flowers during mourning. Instead, acts of charity or food might be a more appreciated gesture.

Additionally, for some Buddhist funerals, sending white flowers is the most appropriate gesture, as they symbolize sorrow and mourning. Conversely, red flowers, usually signifying happiness and celebration in many cultures, are considered inauspicious.

It’s a gentle reminder that in our intent to comfort, it’s essential to be sensitive to the cultural and religious backgrounds of the bereaved. The golden rule? When in doubt, always check with the place of worship or funeral home.

The Extra Mile: Personalizing Floral Tributes

Consider a situation where an ardent lover of literature departs. In remembrance, you might send a bouquet accompanied by a bookmark or a quote from their favorite book. This personal touch elevates the gesture from a mere tradition to a heartfelt memory.

Similarly, understanding the deceased’s passions or hobbies can guide a more personalized tribute. A gardener might be remembered with a pot of blooming roses or a bird-lover with a floral arrangement shaped like a bird.

Concluding Blooms

To wrap our exploration, remember that flowers are more than just a customary tribute. They are a medium of expression, a way to weave stories, and an emblem of life’s transient beauty. In moments of loss, they silently whisper love, remembrance, and hope.

So, as you stand by the blooms in a shop, think not just of tradition but of tales, emotions, and memories. Think of the language each petal speaks and the comfort it can bring to a grieving heart. After all, in moments of silence, it’s often the flowers that speak the loudest.

Complete Article ↪HERE↩!

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It’s good to remember

— We are all on borrowed time

By

Getting older is almost like changing species, from cute middle-aged, white-tailed deer, to yak. We are both grass eaters, but that’s about the only similarity. At the Safeway sushi bar during lunchtime, I look at the teenage girls in their crop tops with their stupid flat tummies and I feel bad about what lies beneath my big, forgiving shirts but — and this is one of the blessings of aging — not for long. Aging has brought a modicum of self-compassion, and acceptance of what my husband and I call “the Sitch”: the bodily and cognitive decline that we all face sooner or later. Still, at Safeway, I can’t help but avert my eyes. Why push my luck?

Twenty years ago, when I turned 50, I showed the dark age spots on my arms and the backs of my hands to my wonderful dermatologist.

“They used to call these liver spots,” I said, laughing.

There was silence. “They still call them liver spots,” he replied.

My mother died of Alzheimer’s disease when I was 50; my father had died of brain cancer 25 years before, so I have always been a bit more tense than the average bear about increasing holes in my memory, and more egregious moments of dither. I thought of my 50s as late middle age.

At 60, I tried to get this same dermatologist to authorize surgery to remove the pile of skin of my upper eyelid that gathered like a broken Roman shade at the eyelash line. “Look,” I said, “the eyelid has consumed my eyeball. I will not be able to see soon.”

I pulled out an inch of skin to demonstrate my infirmity.

He pulled out three inches of his own. “Ticktock,” he said. And he was right. All things skin had gone to hell, from the crepe of my forearms to lots of new precancerous lesions that he routinely froze off or biopsied, once making me use a horrible burning cream all over my face that turned me into Peeling Tomato Girl.

So many indignities are involved in aging, and yet so many graces, too. The perfectionism that had run me ragged and has kept me scared and wired my whole life has abated. The idea of perfectionism at 60 is comical when, like me, you’ve worn non-matching black flats out on stage. In my experience, most of us age away from brain and ambition toward heart and soul, and we bathe in relief that things are not worse. When I was younger, I was fixated on looking good and impressing people and being so big in the world. By 60, I didn’t care nearly as much what people thought of me, mostly.

And anyway, you know by 60 that people are rarely thinking of you. They are thinking about their own finances, family problems and upper arms.

I have no idea of the process that released some of that clench and self-consciousness, except that by a certain age some people beloved to me had died. And then you seriously get real about how short and precious life is. You have bigger fish to fry than your saggy butt. Also, what more can you lose, and what more can people do to you that age has not already done? You thought you could physically do this or that — i.e., lift the dog into the back seat — but two weeks later your back is still complaining. You thought that your mind was thrilling to others, but it turns out that not everyone noticed, and now they’re just worried because your shoes don’t match.

Anyway, as my dermatologist hinted, the tock did tick, and one day he was gone. He retired. Then last year, I heard he died.

>Which brings us to death, deathly old death. At a few months shy of 70, with eyeballs squinting through the folds, I now face the possibility that I might die someday. My dad said after his cancer diagnosis that we are all on borrowed time, and it is good to be reminded of this now and again. It’s a great line, and the third-most-popular conversation we oldies have with each other, after the decline of our bodies and the latest senior moments: how many memorial services we go to these days.

Some weeks, it feels as though there is a sniper in the trees, picking off people we have loved for years. It breaks your heart, but as Carly Simon sang, there is more room in a broken heart. My heart is the roomiest it has ever been.

I do live in my heart more, which is hard in its own ways, but the blessing is that the yammer in my head is quieter, the endless questioning: What am I supposed to be doing? Is this the right thing? What do you think of that? What does he think of that?

My parents and the culture told me that I would be happier if I did a certain thing, or stopped doing that, or tried harder and did better. But as my great friend Father Terry Richey said, it’s not about trying harder; it’s about resisting less. This is right up aging’s alley. Some days are sweet, some are just too long.

A lot of us thought when we were younger that we might want to stretch ourselves into other areas, master new realms. Now, I know better. I’m happy with the little nesty areas that are mine. For some reason, I love my softer, welcoming tummy. I laugh gently more often at darling confused me’s spaced-outed ness, although I’m often glad no one was around to witness my lapses.

Especially my son, who frequently and jovially brings up APlaceForMom.com. He’ll say, “I found you a really nice place nearby, where they’ll let you have a little dog!” Recently, I was graciously driving him and his teenage son somewhere and made a tiny driving mistake hardly worth mentioning — I did not hit anyone, nor did I leave the filling station with the nozzle still in the gas tank — and he said to his boy just loud enough so that I could hear, “I’m glad we live so close to town, so it won’t be as hard for her when we have to take away her keys.”

I roared with laughter, and with love, and with an ache in my heart for something I can’t name.

Complete Article ↪HERE↩!

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Poor End-of-Life Care Can Have Negative Impact on Patients and Caregivers

— A new study aims to answer questions regarding end-of-life care for patients with stage 4 cancers and their caregivers.

By Alex Biese

For patients with cancer and their caregivers, high quality end-of-life care is incredibly important, as one expert explained.

“There has been a fair amount of research done that has shown that when patients do not receive what is considered quality end of life care … not only are there poor patient outcomes — so patients usually tend to have more of a prolonged death, oftentimes they experience more pain, etc. — but it is also usually more traumatic for the caregivers,” said Sara Douglas, the Gertrude Perkins Oliva Professor in oncology nursing at Case Western Reserve University’s Frances Payne Bolton School of Nursing in Cleveland.

“There’s a higher incidence of regret post-death among caregivers, higher incidence of depression and, in some cases, higher incidence of post-traumatic stress disorder, again, depending upon the circumstances,” Douglas told CURE. “And so, there’s been a fair amount of research that has shown that poor-quality patient care at end of life has a negative impact not only on the patient, but obviously on the caregiver who survives and then lives with the decisions that were made at the end of life.”

After decades of research, questions regarding end-of-life care and its impact on patients and their caregivers remain for Douglas.

“The way we conceptualize and approach quality end-of-life care tends to be lacking,” Douglas said. “So, for example, we don’t get information from patients themselves in terms of what it is they want at end of life. And it’s as simple as (asking), ‘Do you want to live as long as possible, regardless of whether or not pain and other things are involved, or is comfort what’s most important to you right now?’”

Through a $3.3 million grant from the National Cancer Institute at the National Institutes of Health, Douglas is set to study variables determining high-quality end-of-life care for patients and caregivers with a five-year study of 300 patients with stage 4 lung, pancreatic and gastrointestinal cancers and their caregivers.

“What I have done in this study — and part of the reason I think the National Cancer Institute was interested in it — is that I am reconceptualizing what it means to deliver quality end-of-life care,” Douglas said. “And what I’m saying is quality end of life care is care that benefits the patient, that we know from the patient themselves what it is they want at end-of-life and that’s what they receive, number one. And it’s also care that does not leave the caregiver wrestling with these untoward emotional issues post-death, such as complicated grief, regret, etc.”

Douglas and her team of researchers will study whether patients are receive care that is in line with their wishes, if the objectives of care for patients and caregivers are in alignment and whether the caregiver is experiencing guilt or suffering complicated grief following their loved one’s passing, according to a news release from Case.

Douglas told CURE that during her time in healthcare attitudes towards end-of-life care have not evolved much in the oncology community.

“We’re not in every exam room, so we don’t know what kinds of discussions are taking place, obviously, but we also know that that oncologists oftentimes are not entirely sure what patients want,” she said. “And caregivers aren’t entirely sure, oftentimes, what patients want.

“And so I think that even in the area of cancer where, regardless of the diagnosis you receive it carries with it a heavy burden (and) oftentimes a feeling that your life has now been shortened regardless of your stage or type of cancer, that we still find reluctance for these discussions to take place until it’s much closer to death and (not) at points where we might have been able to alleviate some of the suffering, or to do a better job of providing the kind of care that was aligned with what the patient’s wishes were.”

Complete Article ↪HERE↩!

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Here’s How To Lean Into Your Holiday Grief Healthily

— Although a joyous time, the holiday season can be difficult for those who’ve experienced immense loss. Learn how to cope with grief and support others who are going through a challenging period.

By Dominique Fluker

The holidays can be notoriously challenging for anyone who has lost a loved one in their lifetime. Those who are processing grief after a close one’s death are probably dreading the holidays, as it’s usually a joyous time reserved for spending time with family members and friends. The holidays can also bring up painful feelings of longing and regret for those grieving, and witnessing other’s happiness may cause anger, resentment, sadness, and pain – as well as feelings of isolation and loneliness, especially if you typically enjoy indulging in holiday traditions. However, there are ways to cope with the holiday grief and to feel supported, uplifted, and cherished through the holiday season. Here are some low-lift ways to cope with the complex feeling of loss during the holiday season.

For those who are experiencing grief this holiday season:

Think about seeking a grief support group: Joining a support group with others who have experienced grief can be a great way to connect with others who understand what you’re going through.

Acknowledge your feelings: Sitting with your grief can be a complicated process, but it’s necessary to confront your pain with the hope of taking steps in your healing process.

Speak to a therapist: If you’re struggling to cope, talking to a professional can be very helpful.

Spend time with supportive family and friends. Surround yourself with people who will make you feel loved, supported, and not judged.

Get involved in your community: Volunteering or other activities, helping others in need, can help take your mind off your grief and make you feel good.

Keep your loved ones’ spirit alive during the holidays: Decorate in their favorite colors or decorations. You can also play their favorite holiday songs, prepare their beloved dishes, look at old photos of them, and listen to recordings.

Here’s how to interact with someone who is grieving loved ones:

Acknowledge their loss. It’s perfectly fine to say something to them about what happened. Avoid phrases like “at least,” “it was for the best,” or “they are at peace now.”

Be an active listener. Let them talk about their loved ones and their grief. Avoid giving advice or telling them how they should feel.

Sit in their grief with them: Sometimes, it’s best not to do or say anything when a person is grieving. Allow them to feel their feelings.

Don’t tell them how to feel: Try not to dictate their feelings by telling them how they should feel. Instead, offer them a safe and soft space to land.

Offer actionable help: Instead of saying, “Let me know what you need help with,” roll up your sleeves and offer practical support, like running an errand, cooking a meal, cleaning up, providing an Uber Eats gift card, or inviting them out for a drink. These small but actionable acts of service will make their lives easier, as most of their thoughts are consumed with grief and balancing their lives outside of their loss.

Be patient and understanding: Grief is a lifelong process that doesn’t magically disappear overnight, as the person in your life who is grieving needs gentleness, understanding, and grace. It’s best to extend compassion and don’t judge their behavior or how they move through the grieving process.

Complete Article ↪HERE↩!

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End-of-life clinicians are trying to shift Hollywood’s depiction of death

By April Dembosky

We’re used to seeing death on TV and in the movies, but some clinicians who work with people at the end of life say the most common depictions aren’t representative of what happens in the real world. They’re trying to shift the stories we tell about death to help people cope better. From member station KQED, April Dembosky reports.

APRIL DEMBOSKY, BYLINE: We’ve seen it so many times – a young man rushed into the emergency room with a gunshot wound, a flurry of white coats racing the clock, CPR, the heart zapper, the order for a scalpel, stat. This is Dr. Shoshana Ungerleider’s biggest pet peeve.

SHOSHANA UNGERLEIDER: Acute violent death is portrayed many, many, many times more than a natural death.

DEMBOSKY: Ungerleider practiced in the hospital and ICU for seven years. She says television tropes like this ignore the full range of end-of-life experiences and the choices people have, like dying at home instead of a hospital. And all those miraculous CPR recoveries – they create false hope. She thinks Hollywood can do better.

UNGERLEIDER: Really, our goal is to encourage them to write in different kinds of inspiring and nuanced and diverse storylines that are more representative of what’s actually possible.

DEMBOSKY: Ungerleider is the founder of End Well, a nonprofit that hosts an annual conference. It’s like the TEDx for end of life.

(SOUNDBITE OF ARCHIVED RECORDING)

UNIDENTIFIED PERSON #1: Please find your seats. Our program is about to begin.

DEMBOSKY: It started six years ago in San Francisco. But this year, it was in Los Angeles for the first time. Ungerleider wants to harness the power of prime-time TV.

UNGERLEIDER: We’re trying to embed ourselves within Hollywood.

DEMBOSKY: In addition to the hospice nurses and grief experts, End Well invited a team of celebrities to the conference stage, like talk show host Amanda Kloots and comedian Tig Notaro. Sitcom star Yvette Nicole Brown was the emcee.

(SOUNDBITE OF ARCHIVED RECORDING)

YVETTE NICOLE BROWN: And when my mom passed, I called all my friends whose mom had passed before and apologized…

UNIDENTIFIED PERSON #2: Yeah.

BROWN: …Because I said, until this moment, I had no idea.

DEMBOSKY: Brown had no models for how to grieve or support others in their grief. Now she’s trying to set an example for the rest of the entertainment industry.

(SOUNDBITE OF ARCHIVED RECORDING)

BROWN: If you are a writer or a producer or a comedian or whatever, talk about grief.

UNIDENTIFIED PERSON #2: Yeah.

BROWN: Talk about death.

DEMBOSKY: End Well has also partnered with researchers at USC Annenberg to find out what’s stopping TV producers from using more realistic death narratives. Director of research Erica Rosenthal says they found Hollywood execs are wary that depressing stories will alienate viewers.

ERICA ROSENTHAL: Entertainment is still a profit-driven system, and the bottom line is viewership.

DEMBOSKY: She says what many viewers want from TV is escapism, comfort, humor.

ROSENTHAL: How do you make end-of-life care funny?

DEMBOSKY: A few industry outliers are convinced they can.

J J DUNCAN: I hope that we can learn that death stories don’t have to be sad or sappy or depressing.

(SOUNDBITE OF COMPAGNIA D’OPERA ITALIANA, ALBERTO GAZALE, AND ANTONELLO GOTTA PERFORMANCE OF ROSSINI’S “IL BARBIERE DI SIVIGLIA – LARGO AL FACTORUM”)

DEMBOSKY: J.J. Duncan is the showrunner for the new reality show on NBC’s streaming network narrated by Amy Poehler, “The Gentle Art Of Swedish Death Cleaning.”

(SOUNDBITE OF TV SHOW, “THE GENTLE ART OF SWEDISH DEATH CLEANING”)

AMY POEHLER: What is Swedish death cleaning, you say? Basically, cleaning out your crap so that others don’t have to do it when you’re gone.

DEMBOSKY: In the first episode, three Swedes help a 75-year-old woman sort through her belongings and her memories, including working as a singing waitress in Aspen.

(SOUNDBITE OF TV SHOW, “THE GENTLE ART OF SWEDISH DEATH CLEANING”)

SUZI SANDERSON: I sang there for 11 years.

UNIDENTIFIED PERSON #3: Oh.

SANDERSON: And then I got married. And then – well, I have to tell the truth. It ruined my sex life.

(LAUGHTER)

DEMBOSKY: Duncan says Hollywood is slowly opening up. She couldn’t believe producers were willing to do a show with the word death in the title.

DUNCAN: I mean, that alone is amazing. And we had studio people say, oh, don’t say death too much, you know what I mean? Because it’s scary.

DEMBOSKY: But Duncan says any good story has setup, conflict and resolution – maybe a hero’s journey. There’s no reason death can’t fit into the formula.