Month: February 2024

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My pets have stolen my heart again and again.

— I know I’m not alone.

Our relationships with animals can be as strong as those we have with humans, and far less complicated

By Marlene Cimons

The most searing memory of my childhood was the day my mother finally agreed to get us a puppy, only to change her mind several hours later. She decided it would be too much work. Growing up, all I ever wanted was a dog or a cat. All I ever got was a turtle, countless goldfish and two parakeets.

Not surprisingly, the first thing I did after leaving home was get a kitten, a half-Siamese who lived to nearly 20, then a Burmese who made it to 17. When my kids were old enough — 10 and 13 — we got a chocolate lab puppy, as much for me as for them. The kids grew up and left, but Hershey stayed. She was my first dog and — with no husband or partner — my best friend.

The years brought a half-dozen more cats and two more dogs, Watson, a black lab then age 6 months, and Raylan, a yellow shepherd mix, who, at 4 years old, arrived with a BB pellet in his leg and a clear case of post-traumatic stress. With patience and love, Ray morphed from a fearful defensive stray into a devoted and trusting companion.

Today I live with Watson, now 10, the king of fetch, a mama’s boy who follows me everywhere; Chloe, 15, a long-haired part-Maine Coon cat, who loves dogs more than other cats; and Zachy, 10, a gray and black tabby obsessed with food — and my socks. All are rescues.

It was predictable after my pet-deprived youth that I would have animals. What surprised me was the intensity of my feelings for them, and how much my relationship with them would come to define my life.

I was paralyzed with grief and guilt (did I do the right thing?) when Hershey, at 13, was diagnosed with an advanced untreatable cancer and I had to let her go. Similarly, I fell apart after Raylan, then 12, and two of the cats, Max, almost 18, and Leo, 15, also developed cancer, and — in a recent short time span — were gone. Today I feel intermittent anxiety about Watson, Chloe and Zachy, the scientific term being anticipatory grief.

Social media is rife with personal stories of the animal/human bond, especially how difficult it can be to say goodbye. Our relationships with our pets often are as strong as and sometimes stronger than, those we have with our humans, and far less complicated. This may explain our deep connection with them.

“Often, pets are our first or even only chosen family when we leave childhood homes, when we live alone, when our children leave, when we go through breakups,” says Marjie Alonso, former executive director of the International Association of Animal Behavior Consultants and the IAABC Foundation. “Our pets provide a steady, stable presence in a way humans do not.”

Researchers sometimes use attachment theory to describe this bonded relationship between humans and their pets, which holds that humans are born with an innate need to bond with a caregiver, usually their mother. “For many pet owners, the attachment relationships we develop are as emotionally close and similar in intensity as a human attachment,” says Michael Meehan, a senior lecturer in veterinary science at Massey University in New Zealand. “Our pets also display the same attachment behavior toward us.”

Sandra McCune, visiting professor in human-animal interaction in the schools of psychology and life sciences at the University of Lincoln in England, agrees. “It may be that companion animals have hijacked our innate desire to form attachments,” she says. “They depend on us like a child that never grows up.”

My companion animals make up the rhythm of my days — and nights. It’s not just the walk/runs with Watson, or his endless preoccupation with tennis balls, or ensuring Chloe gets her medicines on time, and that Zachy has the special food he needs to prevent urinary blockages.

It’s also those exquisitely sweet moments: Watson, warm against my back while I sleep, and Chloe, who starts on my stomach, then moves into the crook of my arm when I shift. Zachy, still dog-wary, stays downstairs overnight, but waits at the bottom of the steps and demands breakfast as soon as he hears us stir.

“Pets tend to be always the same, even on good and bad days, reliably who they are and reliably ours in our relationship with them,” Alonso says. “Their own needs and wants are fixed around food, enrichment and care, focusing on us, rather than ‘Is my promotion going to come through?’ ‘You forgot our anniversary,’ or, ‘What do you want for dinner?’”

Emily Bray, assistant professor of human-animal interaction in the University of Arizona College of Veterinary Medicine, agrees. “When they are tuned into us, you have their full attention. They are not texting on their phones,” she says.

My children have their own lives now — and their own cats — and make their own decisions. But pets need us to make choices for them, even when it isn’t easy. “Pet owners have to decide when the time comes for euthanasia, which often complicates grief and doesn’t often exist in relation to human death,” says Meehan, also a pet grief counselor. “Unlike human death, there are no traditional rituals or protocols in place to memorialize a pet.”

McCune calls anticipatory grief a normal response to the prospect of loss. “It’s part of the love you have for them,” she says. “Enjoy them while you have them, make and keep memories for when they go. There are just some very special dogs and cats, the ones that steal your heart, that you constantly involve in your life, and that you change your life for.”

That has been true for me and, as it turned out, for my parents, too. Years after my brothers and I moved out, my sister-in-law gifted my parents, then in their 70s, with their first dog, a cocker spaniel puppy.

Too much work? Maybe. But they were too smitten to care.

Complete Article ↪HERE↩!

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We are all going to die

— During my first several hours administering ashes as a hospital chaplain, I kept cringing.

Chaplain Angela Song, right, places ashes on the forehead of surgeon Michele Carpenter at Providence St. Joseph Hospital in Orange, California, in February 2023.

By Rachel Rim

Inside the vast, dimly lit chapel, I stand beside a stool that holds Q-tips, a number ticker, and a small jar of ash. The chapel is musty and dark, its stained-glass windows allowing little light to permeate the pews. It lacks a cross, bimah, or any other particular faith marker. This chapel is not a gathering place for a specific community but a refuge for the thousands of patients, family members, and staff who enter the Columbia University Irving Medical Center each day.

Nurses in navy scrubs begin to queue outside the entrance, and I ready a Q-tip in one hand and the jar of ash in the other. Then, as each person squats before my five-foot frame, I check their badge, make a black cross on their forehead, address them by name, and say, “Remember that you are dust, and to dust you shall return.”

Most of them murmur a thank-you and leave; a few walk past me to sit silently in the pews. One or two enthusiastically tell me how glad they are that the hospital offers ashes on Ash Wednesday. The mood, however, is mainly somber, and I wonder as I administer the ashes what these colleagues of mine—nurses and doctors and social workers—are thinking as they receive a sign of death on their bodies before making their way to the dying bodies they are caring for.

Ash Wednesday is the busiest day of the year for our spiritual care department. It’s a whole-team affair: the Catholic priest attends to specific sacramental needs, the chaplains who are comfortable with the imposition of ashes each cover an assigned part of the hospital, and those who are not handle the litany of calls and referrals that make up a day at the hospital. Like a symphony, it takes everyone doing their part to play the piece.

Last year, the day after Ash Wednesday I was sitting with my chaplain cohort when I saw a New York Times article about a man who was being investigated for hate crimes after multiple incidents in which he punched Asian Americans on the subway. I found myself suddenly in tears, unable to breathe—an intensely physiological response that was unusual for me. When my supervisor, a rabbi, realized what state I was in, she promptly invited me to accompany her and another chaplain friend to visit a colleague who’d gone into labor the day before. We made our way over to the maternity ward and held the beautiful baby. At the new mother’s request, we each spoke a blessing over the infant—one Jewish blessing, one Christian blessing, and one Indigenous blessing, representing each of our traditions. As we stood in the quiet, clean room blessing this new life that had entered the world on Ash Wednesday, my body calmed and I relaxed into the safety of my friends.

The mother, also a rabbi, now says that Ash Wednesday is her favorite non-Jewish holiday. She loves the personal resonance she feels with it as her daughter’s birthday, as well as the memory of the sacred moment of mutual blessing and respect that we shared the following day.

I, too, have come to love Ash Wednesday differently after two years of working in the hospital on this day. For me, the memory of being invited to provide a blessing in my own tradition to this daughter of a rabbi feels like the embodiment of interfaith chaplaincy. It baptizes this day with a kind of hospitality, marking it not merely as a day of somber repentance and meditation on mortality but also one of generosity and grace, a day that all can participate in regardless of their faith tradition.

The first time I administered ashes at the hospital, I was shocked both by how many people—patients, staff, visitors—wanted ashes and by the genuine gratitude and peace they seemed to feel upon receiving them. It felt incongruent to me, to feel peace at a symbol of one’s mortality: Why were they so grateful to have a stranger remind them that they will one day die? I felt as though I were saying, “Hello, good doctor—receive this sign that one day you will die just as inevitably as all your patients will.” I cringed for the first several hours that I administered ashes.

Then something shifted. I went to the pediatric ward and administered ashes to my patients, the children of parents desperate for hope and healing. I saw how this ritual gave them that hope and healing, the way their eyes closed, their heads bowed in gratitude, and their shoulders relaxed ever so slightly. I remember going into the room of a patient I’d been following for months, a five-year-old girl with leukemia, and feeling both a kind of dread and a strange, unexplainable grace as I marked her and her parents’ foreheads. It meant something—it meant everything, perhaps—that I, too, wore a cross of ash on my forehead as I marked theirs. I was not pronouncing their deaths like some kind of prophet or angel of death; I was joining them, and inviting them to join me, in the knowledge of our universal mortality. In a sense, I was saying, “We are all patients here. We are all going to die. We are all called to join Christ in his death and his resurrection.” Perhaps providing ashes on this holiday was the deepest embodiment of solidarity with sick and dying people that I possessed.

After that experience, I came to see administering ashes to staff differently as well. Rather than feeling like I was dooming the work of the doctors and nurses who came to me with their heads bowed—essentially telling them that no matter how hard they tried or how advanced medical science became, they would ultimately fail—I was relieving them of a burden too great to carry, one that medical providers are too often asked to hold. They are not, in fact, in the business of saving lives—not in the sense of endlessly deferring death, curing people of the disease of mortality.

Human beings cannot be cured of our mortal diagnosis; death will come for each of us at one time or another, no matter how healthy our lifestyles and how frequent our scans and checkups. Perhaps by administering ashes to these doctors and nurses, I was helping remind them of that truth, freeing them even a little from the enormous pressure that they carry. Their jobs are not to cure but to care, not to fix but to heal, until the inevitable and universal healing of our bodies comes in the form of the death we will all one day face.

According to the United States Centers for Medicare and Medicaid Services, physician and clinical services expenditures in 2021 totaled $864.6 billion. An estimated $4.3 trillion was spent on health care that year in the US, $1.3 trillion of it on hospital care. In 2017, a team of Australian health-care researchers reported that so-called futility disputes in that country—wherein patients with an extremely low or zero chance of recovery, such as those who are legally brain-dead, are kept on life-sustaining interventions in the hospital—cost $153.1 million per year.

The story behind these numbers is a complex one, and no single narrative can be extrapolated from it. Nevertheless, it seems clear that Western culture is too often a death-denying culture, one where the inevitable fact of our mortality stands in stark contrast to the billions of dollars spent each year not only on medically futile treatment but also on the many products aimed at denying death, halting the aging process, and alleviating the sting of acknowledging that we are mortal creatures. We know that we will die, but like children who cover their ears to ignore their parents’ commands, we block out the noise of our impending death with any device or entertainment we can find.

Distracting ourselves from death is not necessarily a bad thing. Human beings weren’t designed to dwell endlessly on our mortality, to read constant stories of violence and death on the news and ruminate over the inevitability that our loved ones will one day leave us. Jesus himself, even as he set his face toward Jerusalem and the violent death he knew would come, broke bread with his disciples, debated with his neighbors, and spent hours reclining after supper with friends and strangers.

Nevertheless, there is a difference between appropriate distraction and endless denial, and research has shown that such denial has enormous costs, from medical expenditures to the quality and length of one’s life (Atul Gawande makes this argument powerfully in Being Mortal). For my part, I have come to see Ash Wednesday, with its blunt liturgy and embodied rituals, as a profound antithesis, perhaps even a kind of antidote, to the particularly American denial of death. I now see the hospital setting as a uniquely appropriate stage for the drama of ashes, and its actors—the patients, families, and staff—as the people who have the most to teach us about how to live well as mortal beings, which is above all a question of how to die well.

The dramatization of death in the hospital that happens every year at the start of Lent leaves no room for escape, whether one wears a cross of ashes or shares a room with one who does, whether one is receiving a diagnosis or delivering one. We all bear witness with our bodies to the truth of our finitude, and for one day every year, perhaps we can help heal one another of our tendency to forget. There can be a grace to remembrance, after all. We remember that we are dust and that we will return to dust, and by remembering, we invite ourselves and one another to learn how to live in this fatal time between.

Complete Article ↪HERE↩!

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My dad’s assisted death was a parting gift.

— I wish I’d said so in his obituary

Kelley Korbin wished she’d included the fact that her father had a medically assisted death in his obituary.

In writing about death, we use euphemisms that sometimes obscure how we actually feel

By Kelley Korbin

My father’s death was something I’d worried about for decades — probably since I learned that smoking kills. But years of pre-emptive angst didn’t prepare me for the crushing heartache that landed like a rock on my chest when he finally died from lung cancer at 82 last year.

I couldn’t have known how the deliberate way he chose to die would become part of his legacy. Or that Mom’s reticence would prevent me from sharing with the world that he had medical assistance in dying. I had hoped to honour my father with an obituary that inspired readers to live harder and love bigger. And, I wanted to package his life with all its complexities and idiosyncrasies into an honest tribute that — if you read between 20 column inches — revealed his authentic nature.

For example, I wrote he regaled us with tales that we never tired of hearing, that he was never one for small talk and that he was his most relaxed self when he travelled. I’ll decipher: Dad always prefaced his (albeit entertaining) stories with, “Stop me if you’ve heard this,” and then launched right in with nary a nanosecond pause for interjections; he did not suffer fools and, without a margarita in hand on a tropical beach, he could be pretty set in his ways.

The one thing I didn’t want to couch was how he died.

I’m reticent to use a hackneyed term like transformational but it’s the only one I have to describe what we experienced. Medical assistance in dying spared Dad many indignities and, for the family he left behind, knowing in advance the exact day and time of his death provided us with a chance to say everything we needed to say and send him off steeped in the love he deserved.

As I watched Dad take his last peaceful breath (not a euphemism, it really was), I was flooded with gratitude for living in a country where my father had the option to forgo a long, slow death. I wanted to share it with the world.

The federal government wants another pause in allowing medical assistance in dying (MAID) requests from those suffering solely from mental illnesses. CBC’s Christine Birak breaks down the division among doctors and what it means for patients who have waited years for a decision.

So, I asked Mom.

“Can I write that Dad had MAID in the obituary?”

“I’d rather you didn’t.”

I’m not usually one to demur. But this was my mother — just a day after her husband of 60 years had died. Plus, obituaries cost a bundle, and she was paying.

“OK, no problem,” I said and went on the hunt for a breadcrumb to drop in the obit. Dad’s death was neither “sudden” nor “unexpected” or “tragic,” leaving me unsure of what coded language to use for assisted dying.

In the end, I settled for the truth: Dad died surrounded by his family as the sun set.

Two women and a man pose for a selfie on a rooftop with palm trees in the distance. They’re all smiling.
Korbin’s parents, David and Judi, were married for 60 years.

For the next year, I regretted what felt like a lie of omission. Then, on the first anniversary of his death, Mom said to me, “It’s taken me a while, but now I see that your dad traded a few months of his life to give us a beautiful death.

She was right.

Dad had always been generous with material things, but his deliberate death was perhaps his greatest gift. Watching him make his difficult decision with grace and equanimity was the bravest thing I’ve experienced. We have always been a close family, but I don’t think any of us, even Dad, could have predicted the way sharing this rite of passage would bring us closer. Even a year after our patriarch’s death, I can feel a deeper intimacy between those of us he left behind.

Beautiful indeed.

I took my mom’s opening to probe further.

“Why didn’t you want me to put MAID in the obituary? Were you worried about the stigma?”

“Me? Stigma? Not at all,” she said, “I just didn’t think it was relevant.”

And then she added, “But I do now. So you go and tell the world about your father’s big, beautiful, assisted death.”

Complete Article ↪HERE↩!

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End-Of-Life

— The One Decision AI Cannot Predict

We often talk about personalized medicine; we hardly ever talk about personalized death.

By Dr. Tal Patalon, MD, LLB, MBA

End-of-life decisions are some of the most intricate and feared resolutions, by both patients and healthcare practitioners. Although multiple sources indicate that people would rather die at home, in developed countries they often end their lives at hospitals, and many times, in acute care settings. A variety of reasons have been suggested to account for this gap, among them the under-utilization of hospice facilities, partially due to delayed referrals. Healthcare professionals do not always initiate conversations about end-of-life, perhaps concerned about causing distress, intervening with patients’ autonomy, or lacking the education and skills of how to discuss these matters.

We associate multiple fears with dying. In my practice as a physician, working in palliative care for years, I have encountered three main fears: fear of pain, fear of separation and fear of the unknown. Yet, living wills, or advanced directives, which could be considered as taking control of the process to some extent, are generally uncommon or insufficiently detailed, leaving family members with an incredibly difficult choice.

Apart from the considerable toll they face, research has demonstrated that next-of-kin or surrogate decision makers can be inaccurate in their prediction of the dying patient’s preferences, possibly as these decisions personally affect them and engage with their own belief systems, and their role as children or parents (the importance of the latter demonstrated in a study from Ann Arbor).

Can we possibly spare these decisions from family members or treating physicians by outsourcing them to computerized systems? And if we can, should we?

AI For End-Of-Life Decisions

Discussions about a “patient preference predictor” are not new, however, they have been recently gaining traction in the medical community (like these two excellent 2023 research papers from Switzerland and Germany), as rapidly evolving AI capabilities are shifting the debate from the hypothetical bioethical sphere into the concrete one. Nonetheless, this is still under development, and end-of-life AI algorithms have not been clinically adopted.

Last year, researchers from Munich and Cambridge published a proof-of-concept study showcasing a machine-learning model that advises on a range of medical moral dilemma: the Medical ETHics ADvisor, or METHAD. The authors stated that they chose a specific moral construct, or set of principles, on which they trained the algorithm. This is important to understand, and though admirable and necessary to have been clearly mentioned in their paper, it does not solve a basic problem with end-of-life “decision support systems”: which set of values should such algorithms be based on?

When training an algorithm, data scientists usually need a “ground truth” to base their algorithm on, often an objective unequivocal metric. Let us consider an algorithm that diagnoses skin cancer from an image of a lesion; the “correct” answer is either benign or malignant – in other words, defined variables we can train the algorithm on. However, with end-of-life decisions, such as do-not-attempt-resuscitation (as pointedly exemplified in the New England Journal of Medicine), what is the objective truth against which we train or measure the performance of the algorithm?

A possible answer to that would be to exclude moral judgement of any kind and simply attempt to predict the patient’s own wishes; a personalized algorithm. Easier said than done. Predictive algorithms need data to base their prediction on, and in medicine, AI models are often trained on a large comprehensive dataset with relevant fields of information. The problem is that we don’t know what is relevant. Presumably, apart from one’s medical record, paramedical data, such as demographics, socioeconomic status, religious affiliation or spiritual practice, could all be essential information to a patient’s end-of-life preferences. However, such detailed datasets are virtually non-existent. Nonetheless, recent developments of large language models (such as ChatGPT) are allowing us to examine data we were previously unable to process.

If using retrospective data is not good enough, could we train end-of-life algorithms hypothetically? Imagine we question thousands of people on imaginary scenarios. Could we trust that their answers represent their true wishes? It can be reasonably argued that none of us can predict how we might react in real-life situations, rendering this solution unreliable.

Other challenges exist as well. If we do decide to trust an end-of-life algorithm, what would be the minimal threshold of accuracy we would accept? Whichever the benchmark, we will have to openly present this to patients and physicians. It is difficult to imagine facing a family at such a trying moment and saying “your loved one is in critical condition, and a decision has to be made. An algorithm predicts that your mother/son/wife would have chosen to…, but bear in mind, the algorithm is only right in 87% of the time.” Does this really help, or does it create more difficulty, especially if the recommendation is against the family’s wishes, or is delivered to people who are not tech savvy and will struggle to grasp the concept of algorithm bias or inaccuracies.

This is even more pronounced when we consider the “black box” or non-explainable characteristic of many machine learning algorithms, leaving us unable to question the model and what it bases its recommendation on. Explainability, though discussed in the wider context of AI, is particularly relevant in ethical questions, where reasoning can help us become resigned.

Few of us are ever ready to make an end-of-life decision, though it is the only certain and predictable event at any given time. The more we own up to our decisions now, the less dependent we will be on AI to fill in the gap. Claiming our personal choice means we will never need a personalized algorithm.

Complete Article ↪HERE↩!

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Should treatment for severe mental illness include medical assistance in dying?

By Anand Kumar and Sally Weinstein

Canada is on the threshold of enacting a law that would make medical assistance in dying (MAiD) accessible to people whose only medical condition is mental illness. If this were to pass, Canada would be one of only a handful of countries to extend that process for patients with serious mental illness.

It will apply to conditions that are primarily within the domain of psychiatry like depression and personality disorders. Political leaders have accused the Trudeau government of promoting a “culture of death;” others see this as a sign of gross underfunding of high demand mental health services.

In the United States, Oregon was the first state to enact the Death With Dignity Act, in 1997. The measure allowed terminally ill adults to end their lives by voluntarily self-administering lethal doses of medication prescribed by a physician for that purpose, with key caveats that included a physician’s diagnosis of terminal illness leading to death within six months. Since then, the District of Columbia and nine additional states have enacted laws that facilitate medication assisted death along the lines of the Oregon model.

Societal expectations regarding MAiD evolved over time. Several European countries have broadened the scope beyond terminal illness and imminent death to include suffering, functional decline and unbearable circumstances with no prospect of improving with treatment, thereby incorporating quality of life metrics into the process.

In a potentially dangerous expansion, countries including Switzerland, the Netherlands, Belgium and Luxembourg currently permit medical assistance in dying for patients characterized as having severe and persistent mental illness (SPMI) — defined as conditions resistant to evidence-based treatments — provided they meet additional criteria that include intolerable suffering with preserved decision-making capacity. By expanding into the realm of mental illness, we change the fundamental nature of the discussion.

Serious mental disorders are in essence brain disorders that are influenced by psychosocial factors. Unlike neurologic diseases, mental disorders cannot be localized to specific regions of the brain. Neuroimaging studies of patients diagnosed with SPMI, including bipolar disorder, the schizophrenia spectrum, anorexia, and post-traumatic disorder, for example, demonstrate that multiple brain regions are involved in the development of these illnesses. These disorders are mediated by impaired brain circuits — interconnected brain regions — rather than any specific part of the brain. The region most consistently involved in these circuits is the prefrontal cortex, which mediates executive functions.

Executive functions include judgment, abstract thinking, planning, integrating information from all brain regions and insight. These domains are therefore compromised in patients with SPMI, with important downstream behavioral consequences that include impaired insight into the nature of their illness and loss of the ability to objectively consider the pros and cons of intervention.

This is not to suggest that all patients with SPMI have minimal insight or are incapable of making rational decisions about their health care. Far from it. But it must be acknowledged that not all diseases, not even all brain disorders, are the same, and some of them do adversely impact cognitive domains germane to consequential decision-making.

There are effective treatments, both pharmacological and psychotherapeutic, that can reduce the burden of disease and improve the quality of life for patients with mental illness. Some of them require long treatment trials using traditional approaches or with newer neuromodulation techniques, such as transcranial magnetic stimulation.

A major compounding factor for patients with SPMI is the lack of adequate access to psychiatric care. Insurance companies frequently use a ‘business model’ approach that maximizes profit; for those with insurance, especially publicly funded insurance that is increasingly privatized, payment is often denied or limited. Denial of care exacerbates the challenges patients face as they navigate our health care system and potentiates the desire for an “exit plan.” Like the current debate in Canada, adequate mental health services and access to care will serve as mitigating factors favoring life in a subgroup of patients.

The notion that there is a right dose and combination of medications for all patients that will eventually result in symptom remission is more folklore than science. We must be intellectually honest and acknowledge that not all forms of SPMI are curable with appropriate therapy and that some patients remain refractory to treatment even after repeated attempts. Patients may also be overwhelmed by long medication trials and experience hopelessness about clinical remission, which is difficult to disentangle from the very symptoms of these illnesses. Perseverance is often a long game in clinical medicine.

An option for this group would be palliative psychiatry. Palliative medicine — that is, the absence of active medical interventions while providing basic sustenance and support — is more widely appreciated in cases of cancer and other near terminal illnesses where the patient makes an informed decision that quality of life, brief as it may be, is more important than measures to extend life, especially when they cause undue discomfort. Palliative approaches in psychiatry are conceptually comparable and include accepting that severe mental illness can be incurable, avoiding direct treatments with challenging side effects and questionable impact, and offering a support system that helps patients live impactful lives until death.

The American Medical Association’s Code of Ethics maintains that assisting in death violates a fundamental code for medical practitioners. The American Psychiatric Association adopted the same position as the AMA in 2016, stating “a psychiatrist should not prescribe or administer any intervention to a non-terminally ill person for the purpose of causing deaths. Suicide prevention is the bedrock of mental health care throughout the country.”

The debate is clearly a difficult one, fraught with emotions; it needs to incorporate not only new scientific information but also the cultural values and principles of the society in which we live. The relationship between patients with mental illness and the practice of medical assistance in dying is a slippery slope that is likely to get even more slippery over time. We will require great caution and a thoughtful national debate as we move forward.

Complete Article ↪HERE↩!

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I Love the Beautiful Chaos of a Jewish Funeral

— There is something quite moving about all this grief amongst all this routine.

By

It was only relatively recently that I learned that holding funerals within 24 hours was a Jewish custom, and not the general norm. I’ve been extremely lucky in having gone to quite few funerals, and almost all of these have been those of Jewish family members, so it simply didn’t occur to me that we might be doing anything unusual in having them so quickly. Without the understanding that this wasn’t standard practice, I didn’t consider it exceptional — but the impact it has on the process of mourning can be, in my opinion, a significant and unifying one.

In the Torah, we are told that “You shall bury him the same day. His body should not remain all night.” And traditionally, the urgency of the funeral is linked to the importance of returning the body to the earth and allowing the soul to return to God. As a culturally-not-religiously Jewish person, I was unaware of both the scriptural and spiritual reasoning until very recently. I would have placed the emphasis on the emotional reasoning, which argues that the immediate experience of loss, mourning and proximity to death is a deep pain to feel, and one which should not be undergone any longer than absolutely necessary. Now it seems clear to me that it’s more about custom than anything else. Either way, I have come to hold it as an immensely important, beautiful aspect of the Jewish culture around death.

In December, my great-great auntie Marjorie became quite ill and we as a family braced ourselves for an upcoming funeral. She, along with much of my family, lived in Manchester, so in the lead-up to her passing, the London sect of us were on slight tenterhooks in anticipation of journeying up on little notice. In these moments, the banal and the profound are forced to find some kind of harmony. When contemplating loss is simply too vast, logistics take on a special importance.

In some ways, the knowledge that you’re just waiting for a death to occur so that the chain of events can start to unfold can be quite tiring. Maintaining a state of urgency over an extended period of time is logistically and emotionally tricky, and having to be pragmatic in the face of something so sad can feel like an unnecessary added encumbrance. But ultimately, there is no actively good time for a funeral. No one is looking at their diary and finding the perfect date to dedicate to doing something none of us want to do. In some ways, recognizing that the funeral will be hard no matter what, and then allowing it to take precedence over all other commitments, is the best way to allow a loss the appropriate space it deserves in our lives.

When the day arrived, a large portion of it for me was taken up by travel. We woke up to cancelled trains — standard — and then huddled alongside however many other disgruntled passengers at Euston. My mum’s cousin Caroline and I ran at absolute breakneck pace through crowds of people to get seats as soon as the platform was announced. On the drive from the station to the cemetery, we passed innumerable family monuments: the prison to which my uncle was told his parents had been sent in a prank by his cousin, the sandhills where Caroline reported “practically torturing” my mum when they were little, the shop to which it was a very grown up privilege to be allowed to walk to alone. Despite most of my visits to Manchester now being for funerals, the city will always feel full of life. Our memories and our history are part of the fabric of the place, and so many of those who we’ve lost are kept alive in the stories we can’t help but keep telling.

The funeral itself was brief and beautiful. My great-great aunt was a truly incredible person whose innate kindness and protectiveness distinguished her as remarkable to everyone around her. With it all having to come together so quickly, the words people choose take on a special significance: they are candid, and emotional, and cut straight to the core.

And yet, alongside mourning and meaning exists the mundane. People keep being people, and we continue to have to get ourselves from A to B. On the journey back to the station after the funeral, I sat squashed between my uncle and my grandfather in the backseat of my great uncle’s car, and we sat for a short eternity in a gridlock outside my grandma’s primary school, entertained by stories about that time of her life. When we finally got to the station, we caught a train by the skin of our teeth. By holding funerals so quickly, we force our lives to fit into the space around them, and require them to find a way to enmesh themselves into the day to day. There is something quite moving about all this grief amongst all this routine.

Sitting on trains gives you the wonderful gift of time to think. I reflected on my privileged position, experiencing the funeral of someone so beloved as a peripheral mourner, and how this offered another insight into the magic of having a funeral within 24 hours of a death. With this custom, in the direct aftermath of losing someone the people closest to the deceased are immediately wrapped in love. Their family and friends flock to them and make sure they aren’t alone with their grief. The initial experience of living without someone involves being in a room full of people who are there to remember and celebrate them. A funeral within 24 hours catches you just as you fall into the abyss.

And whilst there are undeniable impracticalities, the system manages to account for most. For those who are unable to make it, attending a shiva in the coming days offers them another chance to support and commemorate and mourn for themselves, as well as to contribute to the elongation of the period in which those closest to the deceased are surrounded by care. Whilst the funeral comes quickly, this does not mark the end of the grieving process — rather, it’s the beginning of the talking, processing and feeling. I am grateful that, thanks to Jewish custom, that beginning starts within 24 hours of a death. It’s exactly what we need.

Complete Article ↪HERE↩!

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Let’s stop calling medical aid in dying ‘suicide’

By Kenneth Norton

The New Hampshire legislature is considering a bill to join our Maine and Vermont neighbors to allow New Hampshire residents with a terminal illness, in consultation with two medical providers, the option of ending their suffering and having a peaceful death. As a Licensed Independent Clinical Social Worker who has spent over four decades working to prevent suicide at the local, state, national and international level, I think it is time to look closely at the differences between the two, and stop referring to medical aid in dying as suicide.

Legally, in the 10 states and Washington D.C. where medical aid in dying is allowed, the death is not counted as a suicide death. Medical Examiners and Coroners list the underlying terminal illness, which the person was diagnosed with, as the cause of death on the death certificate of patients who utilize medical aid in dying.

People who die by suicide, for whatever reason, no longer wish to live and feel that they have no other option than death. The person who chooses medical aid in dying wants to live yet has been diagnosed with a terminal illness that will end their life, and may cause intense suffering before they die. They are fully informed of other options including palliative care, hospice, and comfort measures. This is not a decision they are allowed to take lightly or at the spur of the moment. It requires thoughtful controls and two medical opinions in support of specific terminal illness.

A high correlation exists between suicide and mental illness. The person who dies by suicide may or may not be rational, or even competent in that moment. Research shows that many suicide deaths are impulsive. Although the person may have contemplated suicide for some time, it may only be a matter of minutes between making the decision to die and then taking their life. By contrast, in medical aid in dying, people go through a formal process with two medical professionals that includes: an assessment of their mental capability, a determination about their terminal illness, an informed consent process including a review of available options, and a mandatory waiting period

People who die by suicide die alone, and often die by violent means. In New Hampshire, over 75% of suicides involve firearms or hanging. Nationally, over 75% of suicide deaths occur in a home or primary residence. These violent deaths result in trauma for their loved ones who return home to find their loved one dead. The scene, shock, and aftermath are so distressing that many people are no longer able to continue to live in their homes. Suicide deaths can also be traumatizing and contribute to PTSD in first responders who are called to the scene.

Family, friends, and loved ones of a person who dies by suicide can experience intense emotions including shock, guilt, anger, shame, regret, and despair as they try to come to terms with the suddenness of the death, and make sense of the often-unanswerable question: “why?” People who are bereaved by suicide may experience suicidal thoughts and are statistically at higher risk themselves for suicide. Suicide deaths are often devasting and life altering for family and friends resulting in a long and complicated grief process that may last years. It is said the person who dies by suicide dies a single death, but their family/friends are left to die a thousand deaths.

By contrast, the person who goes through the medical aid in dying process, frequently includes loved ones in their decision. Most die in their home, surrounded by their family and friends. The death is planned, and peaceful. Family and friends are left at peace knowing that this was their choice and their suffering is over. To be clear, this does not stop those close people from grieving the death, but it eliminates the “whys” and “what ifs” as well as the trauma from a sudden suicide.

Despite our best efforts, there is still considerable shame and stigma associated with, and experienced by family and friends after a suicide. We should be careful not to contribute to that stigma by extending it to medical aid in dying. Whether you support or are opposed to medical aid in dying, we should acknowledge there are significant differences between the two, and we should stop labeling medical aid in dying as suicide.

Complete Article ↪HERE↩!