Category: Anxiety

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Dying isn’t as bad as you think

The thought of death makes many of us feel frightened, so we barely talk about it. But dying is far gentler than Hollywood would lead us to believe.

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Here’s a delicate truth: we’re all approaching the ends of our lives. Every day counts us down, it’s just that most of us rarely talk, or even think, about it. And when we do, we feel scared of pain and panic and feeling out of control; afraid of sadness and saying goodbye; worried about deaths we’ve seen on TV or in films.

I’ve worked in palliative medicine for over 30 years, helping to improve the conditions of those nearing the ends of their lives. I’ve sat by the bedsides of scores of dying people and it’s taught me a lot about the realities – and misconceptions – of death.

More than half a million people die in the UK each year and almost all of them from a condition that gives at least some warning that death is approaching. If you knew you had limited time left to live, what would you want to do? Who would you want to be with? Are you keen on hospitals? Could your home be suitable? What’s your opinion about being kept alive on a ventilator, even if you’re unlikely ever to regain consciousness? How much treatment is too much? Are you an organ donor?

Here is some good news: death is almost certainly not going to be as bad as you think. Just like birth, death follows a predictable pattern. Initially, illness reduces people’s energy levels. The mechanisms are complex, but the outcome is that they need more sleep. Naps help, but energy is quickly used up, and another snooze is required.

 

At the end of life, there’s an exhalation that just doesn’t get followed by an inhalation. As simple and gentle as that.

As time goes by, those naps last longer and change in character. Although the person doesn’t notice any difference, they dip into unconsciousness for a while, so we’re temporarily unable to wake them. At this point, it’s time to switch any symptom-managing medications to a subcutaneous route like a syringe pump, to stop any symptoms from coming back if we cannot rouse the patient when their medicines are due.

If their illness isn’t affecting their thinking, then a dying person will still appreciate their family and friends when they’re awake, the occasional sip of fluid, perhaps a spoonful of something tasty, although people rarely have much appetite. They may stay in bed. They may appreciate peace and quiet, or their favourite music (I’d prefer BBC Radio 4, by the way). The periods of unconsciousness get longer and, eventually, the dying person is simply unconscious all of the time.

We can change evolution © Scott Balmer

Now, the next change begins: in deep unconsciousness, breathing is driven by the only part of the brain still functioning. This produces an automatic breathing pattern that cycles between deep, sometimes noisy breathing and very shallow breathing. The rate also alternates between fast and slow; there can be gaps that are several seconds long. Saliva may gather in the throat, causing air to bubble through the fluid, which makes a rasping or rattling noise. These noises are a sign of deep unconsciousness, not of distress.

At the end of life, during a phase of slow, shallow breathing, there’s an exhalation that just doesn’t get followed by an inhalation. As simple and gentle as that. Sometimes so gentle that the family around the bed doesn’t notice. No pain or panic; no sense of loss of control. This is what the vast majority of people experience.

By knowing this gentle pattern, dying people can make choices about where and how to be cared for. Their families are often asked to report dying people’s wishes. Do you know the answers? Does your family know yours?

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Can Psychedelics Help Make Dying Easier?

“I need to be in a space where I am not hopeless,” says one terminal cancer patient who is suing the Justice Department and the DEA for her right to use psilocybin

By Shelby Hartman & Madison Margolin

Erinn Baldeschwiler had already been having a rough go of it. A mother of two teens, she was going through a divorce, moving out of her house, and splitting from her business partner all as the severity of the Covid-19 pandemic was becoming a reality. Amid it all, she was diagnosed with stage four, triple-negative metastatic breast cancer. The doctors told her that even with chemotherapy every week — something which she knew would severely impact her quality of life — and immunotherapy every two weeks, she likely had about two years to live.

“It was devastating,” says Baldeschwiler, 49. “I thought, what if I’m not going to be here for my kids? A dear friend passed very suddenly, unexpectedly from cancer a few years back and I just know the pain that it leaves behind. It was really, really heavy.”

Now Baldeschwiler, along with Michal Bloom, another cancer patient diagnosed with stage 3 ovarian cancer in 2017, their palliative care physician, Dr. Sunil Aggarwal, and his clinic, AIMS Institute, are suing the Department of Justice and the Drug Enforcement Administration. Baldeschwiler and Bloom want to try psilocybin, the psychoactive component in psychedelic mushrooms, in a therapeutic context for what’s sometimes called “end-of-life distress,” depression, anxiety, and other mental health challenges that can come along with a terminal diagnosis. 

Kathryn Tucker, one of seven attorneys on the case, says Baldeschwiler and Bloom have the right to access psilocybin under Washington state’s Right to Try law, a law which permits patients with a terminal illness to access drugs that are currently being researched, but not yet approved. The federal government, she says, is wrongfully interfering with that right.

According to Tucker, who has devoted much of her career to helping pass and reform legislation meant to ease the suffering of those at the end of their lives, states are the primary authority for the regulation of medicine. And yet, in January, Tucker says, when she wrote to the Drug Enforcement Administration, on behalf of  Aggarwal, Baldeschwiler, and Bloom, asking them how they should go about accessing psilocybin, the administration wrote back saying they couldn’t because psilocybin is a Schedule I drug on the Controlled Substances Act, the most restrictive category defined as drugs with “no medical use” and a “high potential for abuse.” (Typically, physicians with terminal patients would go straight to a manufacturer to get access to a drug under a state’s Right to Try law, but they needed to write to the Drug Enforcement Administration about the process for access since psilocybin is federally illegal.)

In addition to Washington state, 40 states have Right to Try laws, although they’re all worded slightly differently. (Some use language like “terminally ill” while others say “life threatening,” which could change who qualifies.) Overlaid on top of these state Right to Try laws is a federal Right to Try law, which President Trump signed in 2018. In this case, Tucker and the fellow attorneys are primarily focused on patients’ rights under Washington’s Right to Try law, but are using the federal Right to Try law to bolster their argument.

Both the Washington law and the federal law state that terminal patients can access drugs that are not yet approved by the Food and Drug Administration so long as they’ve successfully made it through the first phase of an FDA-approved clinical trial and are currently being investigated. Psilocybin is currently in the final phase of research before FDA approval, and has shown so much promise for treatment-resistant depression and major depressive disorder that it’s been granted “breakthrough therapy” status by the FDA.

“The DEA just did not know about or did not understand Right to Try and this lawsuit is something of an educational vehicle,” Tucker says. Yes, she says, psilocybin is on the Controlled Substances Act, but in the hierarchy of legislation, The Federal Food, Drug, and Cosmetic Act, which Right to Try falls under, trumps the Controlled Substances Act. Tucker says DEA officials just don’t understand that or are behaving as though they don’t. (The Department of Justice declined to comment for this story.)

“I don’t want my diagnosis to be upsetting and dark and hopeless for my kids,” says Baldeschwiler. “So I need to be in a space where I am not hopeless and there is peace. I know for certain if I’m negative and ‘woe is me,’ and desperate and have feelings of like ‘I just want to check out,’ that’s going to make it a hundred times worse.”

Baldeschwiler first got the idea to do psychedelic-assisted psychotherapy from Aggarwal, who she’d found after looking around for more holistic treatment plans in the Seattle, Washington area. Aggarwal discovered what he says is the extraordinary potential of psilocybin to help cancer patients when working with the psilocybin research group at New York University.

Researchers, going back to the late 1950s, found psychedelics such as psilocybin and LSD showed promise for end-of-life distress as well as a host of other mental health conditions, from alcoholism to trauma. Much of this research, however, is not considered valid by the Food and Drug Administration because it did not follow their current protocols.

After Richard Nixon signed the Controlled Substances Act into law in 1970, there was essentially a decades-long ban on psychedelic research. It was a landmark study, published in the Journal of Psychopharmacology, in 2006 — showing psilocybin holds promise for end-of-life distress in cancer patients — that largely jumpstarted what’s now known as the “Psychedelic Renaissance,” the second wave of psychedelic research in the U.S. since the 60s. The study found that after two or three psilocybin sessions, a majority of participants had significant and positive changes in their mood, while 33 percent rated the experience as the most spiritually significant experience of their life, comparable to the birth of a first child or the death of a parent. Since then, this research has continued with the same results in trials at Johns Hopkins and New York University.

“Many, many patients come to me wanting this,” says Aggarwal of psilocybin-assisted psychotherapy. “They read about it in the news or in Michael Pollan’s book.” He says it’s hard to predict, but there’s surely millions of terminally ill patients who could benefit from psilocybin therapy. In 2021 alone, an estimated 1.9 million Americans will be diagnosed with cancer, according to the National Cancer Institute. That doesn’t even take into account, says Aggarwal, all the other terminally ill patients, such as those with Lou Gehrig’s disease, whom he also works with.

Susan Patz, a 62-year-old woman with Lou Gehrig’s disease, filed an Amicus brief, a statement which can be filed to the court by someone in favor of a particular side of a case, for this lawsuit. Patz lives in the town of Monroe, Washington, where her husband John is now her caretaker as she slowly loses agency over her body and even her ability to breathe and swallow. 

“Because of the ALS, I have had to give up a lot of the activities I was passionate about,” she wrote to the court in a brief filed on May 24th. “I loved gardening, and I used to delight in driving the tractor around our property. I loved to swim at the YMCA five days a week. I loved cooking and trying new recipes. I can no longer do any of those things.” She often stays up until 3 or 4 in the morning, because she can’t sleep; she used to be “foodie,” but now doesn’t want to eat or even see friends for fear that they’ll see her as a “sick person.”

“I am desperate to try something that will work, something that will enable me to experience joy and pleasure again,” she wrote to the court. “If the Right-to-Try laws don’t allow someone like me the chance to try something that may help alleviate my suffering, then what good are they?”

On June 21st, the Department of Justice will file a brief on behalf of the Drug Enforcement Administration. On July 12, the petitioners — Aggarwal and his patients — will be given the opportunity to reply. And then, likely in September, the oral argument will take place in which, Tucker says, they may get their first insights into where the court stands on the case. She’s hopeful that perhaps they won’t even get that far, though, because the Drug Enforcement Administration will reach out with the intention of finding a resolution.

Either way, Tucker says, if the case passes, the next doctor and patient who want access to psilocybin for end-of-life distress shouldn’t need to take it to court again. If they succeed in Washington, then, she says, doctors and patients in states with Right to Try laws should be able to access psilocybin.

There’s many unknowns, however, about how doctors and patients would go about notifying the DEA when they’re going to conduct psilocybin therapy — and how they would access the psilocybin itself. Currently, under Right to Try laws, doctors don’t need government approval at all — they can go straight to manufacturers to request access to a drug that’s under investigation for their patient. But the process might be different for psilocybin and a host of practical issues exist, too, such as that it’s difficult to find federally-licensed labs making synthetic psilocybin as there’s no publicly available directory. At this point, Tucker says, they’re just focused on taking things in “small bites.”

“It kind of kills me that I have to be dying to even possibly have access to this medicine when I think it could be incredibly helpful for so many people that maybe don’t fall into that category,” says Baldeschwiler. “I truly, truly am hoping that we have some open minds and open hearts with regards to the DEA and that they honor the intent and the letter of the law because we fall within it.”

Complete Article ↪HERE↩!

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As a doctor, I’m trying to have more empathy for my patients — and myself

By Joseph Stern

“Well, then. I’m going to die, aren’t I?” my friend asked me from a bed in the emergency room. I faced him and his wife. I had worked with Alan Davidson for 20 years. A recently retired ER attending physician, he came in with new right-sided numbness one Saturday evening.

Initially, the ER team called a “code stroke,” rushing to take advantage of the precious minutes available to administer clot-busting drugs or open blocked arteries before the patient suffers more brain damage. A CT scan suggested not a stroke but a brain tumor. I was consulted when an MRI suggested a glioblastoma. We both knew his prognosis was likely poor.

Three days later, I took him to surgery, aware that he was trusting me with his life. When he awoke, Alan and I were pleased that his numbness was no worse and he had no weakness. The postoperative scan showed we had removed virtually the entire tumor.

When the pathology came back, I met with Alan, his wife, and his son. I sat on the edge of his bed and told him his diagnosis. Pathology suggested glioblastoma, a malignant brain tumor with a terrible life expectancy. Neither of us was surprised: We both knew this was coming. But he choked up as he expressed gratitude for the care he was receiving.

Holding back my own tears, I told him how honored I felt he trusted me enough to care for him. Previously, I would not have allowed myself to acknowledge my own gratitude to Alan or accept the depths of his gratitude to me: I would have pushed these feelings away.

More than 25 years earlier, I had faced a similar situation with different results. As a resident, I helped my supervising doctor remove a tumor from deep within the temporal lobe of a man in his 30s. The surgery went well, but we knew the patient’s prognosis was dismal. I entered the cramped consultation room and encountered, for the first time, his wife and three small children. They nervously awaited our report.

I couldn’t bring myself to tell them this was an incurable tumor from which the patient would die in the near future. Instead, I parsed my words. They were technically correct, yet detached. Overwhelmed, I had no idea how to face the patient’s family. What they needed was honesty and compassion. Instead, I avoided connecting, leaving someone else to fill in the gaps. To this day, I carry a sense of shame and failure: I avoided pain, but fell short as a physician.

Physicians develop detachment and emotional distance as a coping mechanism against the pain of grief, loss and failure. Yet our attempts to protect ourselves through detachment ultimately intensify feelings of loss and deprive us of resolution. I have come to see that these unresolved feelings contribute directly to professional burnout.

Mary Buss, director of ambulatory palliative care at Beth Israel Deaconess Medical Center and associate professor of medicine at Harvard Medical School, says that physicians are afraid of, and avoid, feelings of sadness. We reason, mistakenly, that being open to pain and loss could damage us; we fear losing our composure and appearing vulnerable. Yet accepting vulnerability is what most closely connects us with our patients. This is what they remember in the end, after all. Patients crave acceptance, appreciation, and acknowledgment; we all want this for ourselves.

As the brother of a patient, I discovered how it felt to be on the receiving end of care lacking in compassion as I observed occasional blunt, insensitive or confusing comments from the medical staff. I became determined to connect more deeply with my patients and my own emotions. Yet I wondered: How could I balance connection and detachment as a neurosurgeon? Did connecting emotionally with my patients mean I could no longer detach enough to be an effective surgeon? Would it be better to become a technician and leave the emotions to others

I found my approach through a conversation with Helen Riess, a psychiatrist and author of “The Empathy Effect: Seven Neuroscience-Based Keys for Transforming the Way We Live, Love, Work, and Connect Across Differences,” who explained that through the process of developing self- and other empathy, emotional armor could be replaced by “emotional agility.” Intrigued, I went on to read Susan David’s “Emotional Agility: Get Unstuck, Embrace Change, and Thrive in Work and Life,” which characterizes this healthier stance.

Emotional agility enables us to move easily between powerful emotions, recognizing feelings without becoming bogged down by them; to move fluidly through life’s demands without becoming stuck or overwhelmed.

Emotionally agile people derive power from facing, not avoiding, difficult emotions. By allowing ourselves to be vulnerable, physicians become better able to connect more deeply with our patients and ourselves. I came to appreciate that it is possible to move between dispassionate technical precision and intense emotional connection without having to choose between them.

I sat with Alan and his family after his surgery, and we talked until I had to return to the operating room for another case. As I left, Alan remarked that I seemed to get energy and joy from my work. I was surprised to realize that I did feel energized, not depleted; privileged to witness both the beauty and fragility of life. At that moment, I knew I had discarded my suit of emotional armor. In its place was something better and more powerful: emotional agility.

Weeks later, Alan was readmitted to the hospital with increasing right-sided numbness. I read him a draft of this essay as he sat in his hospital bed, unable to control his computer or phone yet intellectually forceful and emotionally attuned. He said that he wanted me to tell his story. He felt strongly this message must be shared, agreeing that doctors often carry a burden of private grief and perceived failures.

We spoke of his children, his grandchildren, his wife. He told me of professional mistakes and a sense of failure that haunted him, yet he also spoke proudly of the thousands of patients he had cared for, their individual stories and faces no longer distinct but flowing through him.

Sitting at my friend’s bedside, I saw Alan forgive himself. He always tried to do his best.

Sometimes, he failed. Just as I often felt powerless, unable to pull someone from the wreckage I saw coming, yet I had done my best. As a resident years ago, knowing that a young husband would not live for long and that his children would lose their father, I had done all I could do — except to allow the enormity of this loss to wash over me, to share it with his family and to accept it, as Alan was doing in his own life

Alan reinforced for me that it is possible to be a skilled surgeon and also a caring and emotionally connected doctor; to hold someone’s hand, and to be present. I couldn’t repair my failed conversation with that family, but I can learn from my mistakes. As long as I continue to practice, there will be another opportunity to try to get things right.

And, as Alan told me, these lessons hold for our lives beyond practice. Part of emotional agility is self-compassion, often a sticking point for physicians. We tend to be unforgiving of ourselves (and of our colleagues). Just as we need to recognize and admit our failings, we also need to let them go. We must forgive ourselves and each other.

These are essential steps toward accepting our vulnerability and achieving emotional agility. Only then can we abandon our detached and defended selves and make the connections that sustain and enrich us.

Alan Davidson, born Jan. 6, 1942, died June 26, 2020. Joseph Stern is a neurosurgeon in Greensboro, N.C. He is the author of “Grief Connects Us: A Neurosurgeon’s Lessons on Love, Loss, and Compassion,” published in May by Central Recovery Press. His website is josephsternmd.com.

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The Secret to Happiness?

Thinking About Death.

In an excerpt from his new book, journalist Michael Easter travels to Bhutan to learn about how confronting death head-on can lead to a more fulfilled life

By Michael Easter

In his new book, The Comfort Crisis, Michael Easter investigates the connection between modern comforts and conveniences and some of our most pressing problems, like heart disease, diabetes, depression, and a sense of purposelessness. Turns out, engaging with a handful of evolutionary discomforts can dramatically improve our mental, physical, and spiritual wellbeing. One of those fruitful discomforts? Thinking about dying.

Death has always been the most uncomfortable fact of life. And as modern medicine, comforts, and conveniences have given us more years, we’ve seemingly become less and less comfortable with life’s only guarantee. Roughly seven out of ten Westerners say they feel uncomfortable with death. Only half of people over 65 have considered how they want to die.

After someone dies we’re encouraged to stay busy to take our mind off it. A dead person’s body is immediately covered and sent to a mortician where it is prepared to look as youthful and alive as possible before one final, hour-long viewing, after which it is dropped into the ground of a perfectly manicured cemetery.

But new research is showing that death awareness is good for us. For example, scientists at the University of Kentucky had one group of people think about a painful visit to the dentist and the other contemplate their death. The death thinkers afterward said they were more happy and fulfilled in life. The scientists concluded, “death is a psychologically threatening fact, but when people contemplate it, apparently the automatic system begins to search for happy thoughts.”

The country of Bhutan has made it part of its national curriculum to think about death anywhere from one to three times daily. The understanding that we’re all going to die is hammered into Bhutan’s collective conscience, and death is part of everyday life. Ashes of the dead are mixed with clay and molded into small pyramids, called tsa tsas, and placed along heavily trafficked areas like roadsides, in window sills, and public squares and parks. Bhutanese arts often center around death; paintings of vultures picking the flesh from corpses, dances that reenact dying. Funerals are a 21-day event where the dead body “lives” in its house before being slowly cremated over fragrant juniper trees in front of hundreds of friends and relatives.

All of this death is doing anything but bumming out the Bhutanese. Despite being ranked the 134th most developed nation on earth, extensive studies conducted by Japanese researchers have found that Bhutan is among the world’s 20 happiest countries. But what you probably don’t know is how morbidity contributes to their feelings of happiness. And neither did I.

After four flights across 48 hours, 14 time zones, and 9,465 miles, I stepped off an aging 737 onto a runway 7,333 feet above sea level at Bhutan’s Paro International Airport. THE thin air filled my lungs as the sun illuminated the surrounding snow-capped Himalayan foothills. I was there to find out how Bhutan’s uncomfortable intimacy with death might improve my life—and maybe yours too.

I’d arranged to meet with a host of characters, including government leaders who study happiness in Bhutan. But the most compelling men I met with were both leaders in the Buddhist faith.

The first was Khenpo Phuntsho Tashi. He knows as much about death as a living human can. He’s one of Bhutan’s leading Buddhist thinkers, and he’s found a niche in the study of death and dying. The Khenpo is the author of a 250-page book called “The Fine Art of Living and Manifesting a Peaceful Death.” And unlike many of Bhutan’s monks, the Khenpo is intimately familiar with what ails people in the West. Before he dedicated himself to his spiritual practice he lived in Atlanta, with a girlfriend who was the Dalai Lama’s translator. He, I thought, would be able to get to the heart and consequences of the West’s fear of death.

My boots kicked up a low-hanging dust as the Khenpo’s cliff-side shack came into view. It was wooden, tin-roofed, and in the shadow of Dakarpo. Dakarpo is an ancient Buddhist monastery built on an outcropping that overlooks the Shaba valley. Fifteen or so people walked clockwise around the white, fortress-like monastery. They chanted as they carefully stepped around its rocky terrain. Bhutanese mythology says a person will be cleared of all of his or her sins by circumventing the Dakarpo 108 times. Each lap takes roughly 25 minutes. The full 108 takes most pilgrims about four full days, a relatively small fee for absolute absolution.

The scent of burning incense crawled into my nose as I peeled back the heavy orange embroidered silk drape leading into the Khenpo’s room. Light was entering the room through a hazy window, catching smoke. It obscured a small altar anchored by a three-foot statue of the Buddha. Around it were smaller Buddhist statues, photographs, and burning sticks of champa. Through the smoke I saw the profile of a face. It was the Khenpo.

“Welcome,” said the Khenpo, his voice a heavily accented butter. I bowed and sat. “You want to talk about death?”

I nodded. “Hmmmm,” he said. His chest slowly rose and fell in the silence.

“You Americans are usually ignorant,” he said, using a word often seen as an insult in the United States, but that by definition means “lacking awareness.” In Bhutan and other Buddhist countries, “ignorance” is the rough English translation of “Avidyā.” That’s a Sanskrit word that means having a misunderstanding of the true nature of your reality and the truth of your impermanence. “Most Americans are unaware of how good you have it, and so many of you are miserable and chasing the wrong things.

“You act like life is fulfilling a checklist. ‘I need to get a good wife or husband, then I get a good car, then I get a good house, then I get a promotion, then I get a better car and a better house and I make a name for myself and then …’” he rattled off more accomplishments that fulfill the American Dream. “But this plan will never materialize perfectly. And even if it does, then what? You don’t settle, you add more items to the checklist. It is the nature of desire to get one thing and immediately want the next thing, and this cycle of accomplishment and acquisitions won’t necessarily make you happy—if you have ten pairs of shoes you want 11 pairs.”

The Khenpo then pointed out that by pursuing this checklist, we’re often forced into acts that take us away from that higher reality and happiness. He was echoing a sentiment shared among many leaders in the tradition of Vajrayana Buddhism. Sogral Rinpoche in his 1992 work The Tibetan Book of Living and Dying called this checklist phenomenon “Western laziness.” It consists of “cramming our lives with compulsive activity, so that there is no time at all to confront the real issues … If we look into our lives, we will see clearly how many unimportant tasks, so-called ‘responsibilities’ accumulate to fill them up … Going on as we do, obsessively trying to improve our conditions, can become an end in itself and a pointless distraction.”

The average American works 47 hours a week. Our entrepreneurs and “productivity gurus” preach that a “grind” and “shut up and work harder” mentality is the secret to satisfaction. This upset in our work/life balance—or, perhaps, our problem integrating our work into our life and not the other way around—factors into why other research has shown that America is, in fact, less happy than it was decades ago.

“So this checklist plan does not make you truly happy. Then what?” said the Khenpo. He was silent. Left it open for me to ponder.

“I don’t know. I’m an ignorant American,” I said and smiled.

“Then you could be happier!” he responded with a chuckle. “Whereas if you understand this cycle and nature of mind and you prioritize mindfulness then everything will be ok. Even if you don’t become rich. Fine, you’re mindful. Even if you don’t get a perfect wife? Fine, you’re mindful.”

Ah, yes. “Mindfulness.” That squishy, what-the-fuck-does-that-even-mean word that’s so hot in America today but has, in fact, been a part of Eastern traditions since before Christ. It’s roughly defined as purposefully paying attention to what’s happening in the present moment without judgment, according to Jon Kabat Zinn, a profes-sor at the University of Massachusetts Medical School and pioneer of mindfulness in the Western world. In other words, it’s being aware of what’s going on upstairs.

The Khenpo made mindfulness sound akin to jamming a stick into the spokes of the checklist and developing a state of okayness. In other words, whether I’m rich or poor or famous or a nobody, I should avoid becoming caught up in the narratives my mind spits out and just accept the direction of things. This will help me go beyond the checklist and be just fine.

The woman who took me through the cleansing ritual entered the room. She placed a plate of sliced cucumbers and mandarin wedges on the floor between the Khenpo and me. “All organic!,” he said and grabbed a spear of cucumber. It crunched as he bit into it.

“Well, the Bhutanese, we also have ignorance, anger, and attachment. We have the same problems of the checklist. But I think less. This is because we apply what we call mindfulness of the body. We remember that everyone is dying right now,” said the Khenpo. “Everyone will die. You are not singled out. Do you know this? To not think of death and not prepare for it … this is the root of ignorance.”

Pretend you are walking along a trail, he explained, and there is a cliff in 500 yards. The catch: The cliff is death and we will all walk off it. “Buddha died. Jesus died. You will die. I will die. I would like to die on that bed,” said the Khenpo, pointing to a twin mattress on the floor.

“Don’t you want to know that there’s a cliff?” he asked. Because only then can we change our course. We could take a more scenic route, notice the beauty of the trail before it ends, say the things we truly want to say to the people we’re walking it with.

“When you start to understand that death is coming, that the cliff is coming, you see things differently. You change your mental course—you naturally become more compassionate and mindful,” said the Khenpo. “But Americans, they don’t want to hear about the cliff. They don’t think about death. After a funeral, they want to get their mind off the death and just eat cake. The Bhutanese, they want to know about the cliff and they will be happy to talk about death and ruin the cake eating.”

“So remember,” he continued. He was able to sustain the perfect upright lotus position while I was slumping and couldn’t feel my legs. “We are all dying right now. To develop this mindfulness of death you have to think of Mitakpa.”

“Mitakpa?” I asked.

“Yes,” he said. “Mitakpa.”

Before I could probe the Khenpo on Mitakpa—what it is and what it might be able to do—his time was up and I was back in Dorji’s hatchback. We were like bouncy balls in the seats as gravity aggressively pulled the car over all the rocks and ruts that once thwarted us. As we descended I asked, “Dorji, what is mitakpa?” He looked at me and shook his head. “Mi-tak-pa,” I said.

“Oh. Mitakpa,” he replied, pronouncing the word less like an ignorant American. “Takpa ‘permanent,’” he said. “Mi ‘no.’ Mitakpa ‘no permanent.’”

I began to ask him to explain further, but a Bhutanese traffic jam interrupted me. A herd of seven bulls and cows ambled up the one-lane road. Dorji pressed into the brake to slow the car to a crawl. The half-ton animals lazily parted around us. Their bells clanked as they slid down the length of the hatchback.

The next day, I headed into an apartment in the city of Thimpu to meet Lama Damcho Gyeltshen. He doesn’t ponder death in any abstract sense—he experiences it every day. He’s the head Lama at the Jigme Dorji Wangchuck National Referral Hospital, the main hospital in Bhutan. It’s there that he councils the dying. After the Khenpo elucidated the problem and hinted at some solution, the Lama, I figured, might be able to expand.

The Lama was sitting on a platform that was covered in silk meditation pads. He hopped off of it as we entered. He and I shook hands and did a lot of smiling and nodding. He was bald, short, and doughy, with wire-framed glasses. His bright white smile popped against his blaze orange robes. He sat back atop the platform, in the lotus, while Jigme and I sat on the floor. Jigme explained what I was there to talk about. Death, dying, and the Bhutanese death complex.

“Well first I’d like to thank you for coming and reminding me of death because it is important for the mind,” said the Lama. His words, naturally, set me up to ask why.

“When people come into my hospital there is a chance they leave,” he said. “But there is also a high chance they do not leave. My job is to help people prepare for death. I have found that the people who have not thought about death are the ones who have regrets on their deathbeds. Because they have not used a necessary tool that could have made them live a fuller life.” An American study conducted across various hospitals like the Yale Cancer Center, Dana -Farber Cancer Institute, and Massachusetts General Hospital supports this notion. It found that dying patients who had open conversations about their death experienced better quality of life in the weeks and months leading to their passing, as judged by their family members and nurse practitioners.

“The mind is afflicted with many delusions. But they come down to three,” continued the Lama. “And those are greed, anger, and ignorance. When your mind is not taken care of these three things have an advantage. The dying people I council … they suddenly do not care about getting famous, or their car or watch, or working more. They don’t care about the things that once angered them.” In other words: When a person realizes death is imminent, their checklist and everyday bullshit becomes irrelevant and their mind begins to center on that which makes it happy. Research from Australia found that the top regrets of the dying include not living in the moment, working too often, and living a life the person thinks they should rather than one they truly want to.

“Whereas those who have thought of their death and prepared for it,” said the Lama, “they do not have those regrets. Because they have often not fallen so much into those delusions. They have lived in the moment. Maybe they have accomplished a lot. Maybe they have not. But regardless it has not affected their happiness as much …” He expanded on this phenomenon, explaining that a sort of cosmic psychic shift often occurs in the dying. It brings them closer to the things that matter in the end. A living person who thinks of dying will, yes, initially face mental discomfort, but they’ll emerge on the other side having stolen a bit of this end-of-life magic.

“What is mitakpa?” I asked. “Someone told me it translates to ‘no permanent…’”

“Close. Mitakpa is impermanence,” said the Lama. He raised an arm and finger, like a professor making a point. “Impermanence, impermanence, impermanence.” This, he said, is the cornerstone of Buddhist teachings. Nothing lasts and, therefore, nothing can be held onto. By trying to hold on to that which is changing, like our life itself, we ultimately end up suffering. Buddha’s final words were on impermanence, a reminder that all things die. “All things change. Whatever is born is subject to decay…” he said. “All individual things pass away.”

“It’s important to preserve this precious understanding of mitakpa in your mind. It will significantly contribute to your happiness,” said the Lama. He echoed the Khenpo’s sentiment. He explained that not thinking of mitakpa often leads a person to believe that “things will be better when I do X.” Or with a false sense of permanence that causes a person to put off the things they truly want to do because “I can do that when I retire.”

“But when you understand that nothing is permanent you cannot help but follow a better, happier path,” he said. “It calms your mind. You tend not to get overly excited, angry, or critical. With this principle, people interact with others and it improves their relationships. They become more grateful and gratuitous. Because they realize all their material goods and status will not matter in the end.” And not just in Bhutan. A study in Psychological Science discovered that people who thought about their death were more likely to show concern for people around them. They did things like donating time, money, and even their blood to blood banks.

“How often should I be thinking about mitakpa?” I asked.

“You must think of mitakpa three times each day. Once in the morning, once in the afternoon, and once in the evening. You must be curious about your death. You must understand you don’t know how you will die or where you will die. Just that you will die. And that death can come at any time,” he said. “The ancient monks would remind themselves of this every time they left their meditation cave. I, too, remind myself of this every time I walk out my front door.”

We talked for a half-hour more about death and his work at the hospital. Then it was time for me to leave.

“Remember,” said the Lama as we were saying goodbye. “Death can come at any time. Any time.”

The next day I spent the morning hiking five steep miles to Paro Taksang, “The Tiger’s Nest,” a sacred 15th-century Buddhist monastery built in the traditional Bhutanese Dzong style. The monastery sits at 10,240 feet above sea level and clings to a cliff like a reptile on a vertical wall. It’s the location where in the eighth century Padmasambhava, a man considered the “Second Buddha,” meditated in a tiger-filled cave for three years, three months, three weeks, three days, and three hours.

I’d come to see the monastery’s famous artwork, much of which depicts death. It holds various images and statues of, for example, Mahakala, a protector god whose crown is ringed with skulls and whose sash is strung with severed heads. His Sanskrit name translates to “beyond time” or, more simply, “death.”

As I exited the monastery and put my shoes back on, Dorji, my driver (Bhutanese law requires all tourists to hire a guide and a driver … my guide had conked out due to the altitude), hurriedly approached me. “Someone sick,” he said in his broken English. He pointed up the trail, to a set of steep stairs cut from a cliff that lead up to a small meditation hut next to a waterfall. Towards the top of the steps, a group of people huddled. They were all wearing either traditional Bhutanese ghos or monk robes. Dorji jogged towards the group. I followed. As I quickly stepped up the thin stairs I could see feet hanging from the edge of the steps.

A monk—bald head, thin glasses, maroon robes—was down on the steps, unconscious. I recalled some basic emergency wilderness training I took and checked his spine for signs of fracture. Nothing. A general understanding arose within the group. The man needed to be moved to flat ground so he could be airlifted out.

The stairs were too steep and thin for a group carry. So we carefully propped the monk onto the back of the largest driver, who hoofed him down the steps. With the help of the group, he laid the monk onto a flat grass patch along the cliffside trail.

The monk’s eyes were rolled back as if he was scrutinizing the brain above them. “I’m going to do CPR,” I slowly told the group. They only partially understood me. As I knelt in front of him two tiny women, a mother and daughter who were both doctors in Hong Kong, were suddenly at my side. They were hiking to the monastery when they walked into this scene.

They pressed their fingers to the man’s neck to check vitals and agreed that CPR was needed. These two were surely better trained. But I was the only person with any training who was also large enough to optimally execute CPR on the 200-pound monk.

I tore open his robe, revealing a gold t-shirt. I dug my knees into the dirt, overlapped my hands, and placed the heel of my right hand on the monk’s sternum. Then I began hammering into his chest; 100 beats a minute as the daughter doctor began a timer.

I was unsure of the cultural implications of giving a monk mouth-to-mouth. So the younger Hong Kong doctor quickly instructed one of the other monks, a woman, on how to do it. She breathed into him, repeatedly pushing air into his lungs. Then I was back to compressing his chest.

“Time is 10:26,” said the daughter. A crowd had formed around us, and a driver who was on the phone stepped into the group. “Helicopter cannot come,” he told us. There was nowhere to land, and the cliffs were too close for an airlift.

The daughter checked the monk’s vitals. She shook her head. I continued pressing. Pressing, pressing, as hard as I could, thinking that if I could push hard enough it might kickstart his heart. We hit the fifteen-minute mark. His face was distant. “20 minutes 11 seconds,” said the doctor. “You can stop.” He was gone.

Here was a man who just minutes ago had hiked five steep miles. And he was joking and laughing and talking with friends along the way. Death can come at any time.

Complete Article ↪HERE↩!

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End-of-life care: people should have the option of general anaesthesia as they die

By and

Dying patients who are in pain are usually given an analgesic, such as morphine, to ease their final hours and days. And if an analgesic isn’t enough, they can be given a sedative – something to make them more relaxed and less distressed at the end of life. We have recently written about a third approach: using a general anaesthetic to ensure that the dying patient is completely unconscious. This has been described previously, but largely overlooked.

There are two situations when a general anaesthetic might be used in dying patients. The first is when other drugs have not worked and the patient is still distressed or in pain. The second is when a patient has only a short time to live and expresses a clear wish to be unconscious. Some dying patients just want to sleep.

But what type of anaesthesia are we talking about? If you need surgery or a medical procedure, there are three options. First, being fully awake, but having local anaesthesia to block the pain. Second, you could be partly sedated: you would be less stressed or worried about it, but you might remember some of the procedure afterwards. Finally, you could have a general anaesthetic and be out cold, with no memory of the procedure afterwards.

Any of these might be appropriate, depending on the procedure and depending on the person. But the option with the highest chance that you won’t feel anything is, of course, general anaesthesia.

These same three options could be offered to a dying patient. Some people might want to be as awake as possible. (Like the poet Dylan Thomas, they might not wish to “go gentle into that good night”.) Some might want to be sedated, if necessary. Others might want to be completely asleep.

The choice of general anaesthesia at the end of life is potentially popular. Last year, we surveyed more than 500 people in the UK about end-of-life options. Nearly 90% said they would like the option of a general anaesthetic if they were dying.

You might wonder, is this not just euthanasia by another name? Giving someone medicines to ensure that they are unconscious as they die naturally is different from giving someone medicine to end their life. General anaesthesia is legal, whereas in many countries, including the UK, euthanasia is illegal. This means that the option of anaesthesia could be available now for dying patients in the UK without changing the law. France has recently recognised the right for dying patients to be unconscious.

Wouldn’t it be too risky?

There are side-effects with all medicines, but recent advances mean that it is possible to give anaesthetic medicines to patients close to death without affecting their breathing. The medicine is given slowly, and the patient made unconscious gradually over 15 to 20 minutes. The medicine can be slowed or stopped at any point.

Tray of anaesthetic drugs.
Tray of anaesthetic drugs.

Previous studies that have used anaesthesia at the end of life, have continued the medicines for one to 14 days until the patient died naturally.

This will not be for everyone. It may not be possible for those who are dying in their own home. And some people will not want it. But we have the means to offer dying patients a gentle alternative end to their days. We believe that there is a strong ethical case to make the option of general anaesthesia at the end of life more widely available.

Complete Article ↪HERE↩!

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You’re going to die.

So now what are you going to do about it?

By Laura Pritchett

My position on death? I’m against it.

That said, I will concede I lose that argument, and that moreover, my opinion has never even mattered. Die I will.

And I am not alone in this — you will die, too. After all, death, darn it, just happens. Globally, about 65 million people die each year, 180 per day, 120 each minute. 108 billion people have walked the planet, and then died. That’s a lotta dying, and while it’s incredibly difficult and tragic — this last year especially so — that doesn’t mean we shouldn’t talk about it. Avoidance is not a solution.

Indeed, I’d argue that death is a grand mystery — sacred and important — and this last physical act of our lives can either go pretty well, like a graceful well-rehearsed piano solo or free-throw, or it can go pretty darn badly. Some of how it plays out is beyond our control, but not all of it. Some of it we can prepare for — and if anything deserves our full attention, some preparation, or some renewed clarity, death might be it.

So, the deal is: Tax Day is April 15. But I’d argue the real task — and probably the less miserable one — is to get our stuff in order for Healthcare Decisions Day, which is April 16.

I know: no one wants to do it.

I know: you’re probably starting to X out this essay, or skim it, or scowl at it.

But I’m begging you — and so are your peeps — to take a few hours now in order to save them potentially hundreds of hours. Yes, hundreds of hours. And possibly a lifetime of regret or heartache.

Getting basic and important documents done, and your simple wishes on paper, can literally be your great parting gift.

We all knew someone who left behind a mess — and we all promised ourselves not to be that person. Which means we have to set aside some time and get this stuff done.

First, there’s the medical and legal stuff – Advance Directives and a will – and making sure they’re done, signed, and accessible (they’re really no help if no one can find them). Plus, heck, just leave a note with a trusted person about where some of your stuff is and what you basically want done with it. A great place to start is The Conversation Project.

But in my death-positive work (stemming from my book Making Friends with Death: A Guide to your Impending Last Breath), I advocate writing an ethical will, too — what you stood for, your best and worst times, any reckoning or forgiving or venting or whatever you need to do.

Basically, it’s a “Goodbye letter to life,” if you will. My guess is that doing so will bring you a lot of peace, and will provide peace to those around you, too. Ideally, you don’t want to write this when you’re under duress – write it when you’re feeling great, write it on a lovely spring day, write it on April 16!

Finally, our last task is to advocate simple and direct communication about end-of-life care with those that will likely be involved with it. What looks good to you? What do you want to avoid, if possible? Get clear on what “a good death” looks like for you. Me? I’ve come to believe that a good death is simply one that has been claimed, to the extent possible. For me, that will involve: My medical wishes and decisions being respected (such as my DNR wishes being followed); I would like to die outside, or with a view of nature; I’d like to be with my children and loved ones, if possible; I’d like to be as fully informed about what’s going on, to the extent possible; I want people to be honest with me and I want to be honest with them; and I wouldn’t mind the smell of vanilla or sage and a taste of good whiskey on my lips. Such wishes are written down in about 10 different places, all accessible; my children roll their eyes when I bring it up and say, “Yes, yes, we know, Mom.”

What does yours look like? And who have you told?

Completely bizarre to me is this: A recent Pew Research Center study on end-of life issues found that less than half of people over 75 had given much thought to the end of their lives, and incredibly, only 22% of them had written down or talked to someone about medical treatment at the end of their lives. However, the same Pew study finds a sharp increase in all adults putting something in writing (six in 10 of us) and thinking through our deaths, which indicates that percentage-wise, it’s the slightly younger folks who are preparing now. Attitudes are shifting, too: an unprecedented 66% of us now think there are instances in which doctors should allow a patient to die (instead of doing everything possible to save a patient’s life). A tipping point, it seems to me, has been reached—and we’d like a more mindful, respectful death. We are reclaiming the ancient art of dying.

But there is much to be done. Indeed, though our culture is death-avoidant and confused, I am heartened by the increasingly popular “Death Cafés” and new movements such as “Slow Medicine,” and I’m grateful for April 16, which is the day we should all admit that our life belongs to us, but it also belongs to everyone we interact with, and we owe them the gift of directing an honest gaze at our demise.

But best of all, spending some time now might leave us thinking of death as more of a friend rather than a spooky stranger. With our newfound peace, we can then spend our precious time really living.

Complete Article ↪HERE↩!

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Does Marijuana Have A Place In Hospice?

Marijuana is used in hospice care to ease spiritual and existential suffering, with some studies showing an important therapeutic role for patients faced with the despair of a terminal illness.

BY Kate-Madonna Hindes

As Americans continue to age, hospices are exploring new ways to bring peace and calm to the often slow and painful process of end-of-life care. According to the CDC, in 2015, an estimated 1.4 million individuals on Medicare were patients in a hospice setting.

Quadrupling in size in the last 20 years, hospices are investing in creating a patient-centric approach that dismantles beliefs that hospices are cold, and unfeeling institutions. From massage to aromatherapy, some hospices are offering new additions to their programs including music and integrating family into meaningful experiences. While many hospices are focused on offering a thoughtful quality of care, many end-of-life-care specialists are also advocating for marijuana.

A MorseLife Hospice and Palliative Care study focused on advances in hospice care found changing attitudes on medical marijuana. They cited that, “87% of Americans support the use of medical marijuana as a treatment option for terminally ill patients, with nearly three in five Americans (58%) expressing strong support.”

The American Academy of Hospice and Palliative Medicine recently shared a video on how hospices can integrate medical marijuana into care, heralding more change in the market to accepting marijuana as a part of a patient’s care plan.

Pathways Home Health advocates for marijuana in hospice care, stating:

“Marijuana is used in the hospice care setting to ease spiritual and existential suffering, with some studies showing an important therapeutic role for patients faced with the despair of a terminal illness, as well as the loss of function that accompanies it. A mild euphoria or sense of well-being can ease a patient’s mind, body and spirit as they come to terms with their fate.”

Not Telling Your Doctor About Marijuana Use Can Hurt You

Stuck in political limbo

While some hospice programs are embracing medical cannabis, some are facing uncertainty about whether or not to allow medical marijuana, even when it’s legal inside their particular state. With an ever-expanding list of states that allow marijuana both medically and recreationally, hospices are taking an evidence-based, risk-management-forward approach to ensure they comply legally and ethically.

Changing attitudes are allowing for researchers to gain more insight and information regarding the role cannabis and CBD can both play in hospice and palliative care settings. Published in the Journal of Palliative Medicine, an October 2019 study focused on the responses of over 300 palliative care professionals from over 40 states on the use of medical cannabis. The study found “overwhelming support” for the use of medical cannabis in a hospice setting:

Regardless of legal status, hospice staff members were overwhelmingly in agreement that MC (medical cannabis) is appropriate for hospice patients to have access to and use.

Citing barriers such as legal status, clinical safety, and societal influence, the study believes opportunities exist to better support hospice providers and patients with education, research and policies that elevate the use of medical cannabis.

With new patients entering hospice every day and both clinicians and doctors looking to supplement old pain medicines with newer more effective treatments, marijuana will remain a top topic for years to come.

Complete Article ↪HERE↩!