Category: COVID-19

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The “good death” revolution

—Companion animal euthanasia in the modern age

Home euthanasia sets a peaceful, more relaxed tone.

A good death is achieved by advocating for, and acting on, what is safest for the pet, what is most meaningful for the caregiver, and what will nourish the veterinary team

By Kathleen Cooney, DVM, CHPV, CCFP

Animal euthanasia has come a long way in the past 15 years. With the increased attention given to the human-animal bond, particularly during COVID; the emotional complexity of animals; and the recent and welcomed focus on veterinary wellness, the importance of a good death has risen to center stage. In forward-thinking veterinary practices, the euthanasia appointment is no longer an unpleasant burden in the day, but rather a rare gem of connectedness and intimacy so many of us look for in our professional lives. It provides teams the chance to slow down, to listen to stories, to take deep breaths in quiet reflection in an otherwise chaotic schedule. Euthanasia, while sad and heartbreaking, can lead to rich personal satisfaction when performed well. When love is at the heart of our work, the veterinary profession finds peace, even when life is lost.

Good euthanasia has evolved past the simple “one step” of giving an injection. It orbits around consistent components such as the right timing, compassionate staff, skillful techniques, and loved ones gathered close. The focus has been shifting to ensure the pet’s last moments are comfortable and peaceful, rather than just getting it over with as soon as possible—quality over quickness, in most cases. When it comes to euthanasia, if it’s worth doing, it’s worth doing right, especially since there are no do-overs.

To understand the scope of the “good death” revolution, we need to explore some key game-changing influences that have brought about the shift. The first worth mentioning is the attention paid by the American Veterinary Medical Association (AVMA) and other governing bodies to euthanasia techniques and animal welfare. Numerous revisions have been made to AVMA’s Guidelines for the Euthanasia of Animals, most recently in 2020. The document highlights the value and significance of proper technique choices and the ethical considerations we all must weigh, regardless of the species in question. Are they perfect? No, but they are extremely well-thought-out and closely match peer-reviewed literature. They will improve as research progresses and as society dictates.

A second influencer then has to be society’s demand on veterinary professionals to deliver a death worthy of the life itself. It is well understood pet owners largely view their animals as family members or loving companions. As evidenced further on in this article, loving pet owners regularly view the euthanasia appointment as a modest funeral. More and more are seeking those special touches that pay added respect for their companion.

As a home-euthanasia specialist, I’ve had many families over the years attend the euthanasia of their pet wearing suits and ties. Even though no one would see them, they dressed up to honor the life and the loss. Jessica Pierce, PhD, bioethicist and purveyor of the good death revolution, advocates for what she refers to as the sixth freedom: the freedom to die a good death. She adds this freedom to the already well-known five freedoms of animal welfare. “A good death is one that is free of unnecessary pain, suffering, and fear; it is peaceful; and it takes place in the presence of compassionate witnesses. It is, above all, a death that is allowed its full meaning.” The euthanasia of a family pet is significant and for many, will be their first experience with death.

A third major influence was/is the recognition by many in the veterinary profession that death needed to be more meaningful. The kind of experience we are talking about here is one that leaves the entire veterinary team feeling they provided the best medicine possible and supported the client throughout. Approximately 20 years ago, a small number of veterinarians and technicians throughout North America found just how enriching full devotion to the euthanasia experience can be. They shifted their appointments to focus on the bond as much as the act of euthanasia itself.

Early adopters had numerous things in common. They:

  • Took time to preplan and provide highly individualized care
  • Increased euthanasia appointment times
  • Offered home services
  • Provided sedation or anesthesia to all pet patients
  • Elevated bereavement support

In return for these specialty touches, clients showered them with thank you cards and told other pet owners about the wonderful care they had received. Through eventual collective sharing of their successes in advanced euthanasia work, other veterinary professionals joined in and the modern revolution began. Since 2011, at least seven books have been written focusing entirely on companion animal euthanasia (or contain chapters on the subject), more end-of-life care guidelines are available, and the number of pet bereavement organizations has skyrocketed. Today, there are more and more veterinarians specializing in euthanasia work, many of which offer animal hospice services as well. Animal hospice is a philosophy of care aimed at providing emotional and medical support for the dying pet and caregivers. As of early 2020, the International Association for Animal Hospice and Palliative Care (IAAHPC) touts more than 800 members, a number sure to grow in the coming years.

Have you ever thought about how much really goes into a euthanasia appointment? If you start to explore all the components of a good death experience, it’s no wonder euthanasia appointments are lengthening.

Here is a list of 14 essential components of companion animal euthanasia as developed by the Companion Animal Euthanasia Training Academy (CAETA).* Spelling out “good euthanasia,” each aspires to minimize stress for the pet, provide emotional support for the caregiver, and streamline the actions of the veterinary team.

G: Grief support materials provided
Examples: Printed pet loss guides, books, or direct links to online resources.

O: Outline caregiver and pet preferences
Examples: Talk about what’s important to the caregiver and pet. Match what they need.

O: Offer privacy before and after death
Examples: Make sure a family has time to be alone with their pet if requested.

D: Deliver proper technique
Examples: Always use the most efficient and appropriate technique based on the pet’s health and available supplies.

E: Establish rapport
Examples: Slow down and emotionally connect with the caregiver and pet before proceeding.

U: Use of pre-euthanasia sedation or anesthesia
Examples: Sleep before euthanasia reduces anxiety and pain, and increases technique options.

T: Thorough, complete consent
Examples: Every euthanasia must be properly documented in records.

H: Helpful and compassionate personnel   
Examples: Engage staff to assist who are naturally empathetic. The use of a “euthanasia attendant” is strongly encouraged (more about this later).

A: Adequate time
Examples: Slow down, block out enough time to complete all 14 components.

N: Narrate the process
Examples: Describe what each step of the process looks like, being mindful to keep language simple and uncomplicated.

A: Avoid pain and anxiety   
Examples: Be gentle when handling the pet, use sedation whenever possible, and go slow to reduce anxiety.

S: Safe space to gather   
Examples: Consider using a quiet room in the hospital or performing the euthanasia at home.

I: Inclusion of loved ones
Examples: Talk to caregivers about who should to be there, including other household pets bonded to the one being euthanized.

A: Assistance with body care   
Examples: Preplan with families around what’s important to them and carry out their wishes as if the pet were your own.

In addition to veterinarians carrying out the medical act of euthanasia, vital support staff help ensure everything goes well. Empathetic veterinary technicians, veterinary social workers, assistants, receptionists, and grief support personnel work together to ensure the pet is Fear Free and the client is carefully looked after. CAETA advocates for use of what it calls the euthanasia attendant. This person is responsible for guiding the family unit through the appointment from beginning to end. While many people may be involved in the pet’s care, one consistent person increases the likelihood that everything flows smoothly.

If you’ve been watching for change, you’re sure to have noticed the increase in specialty mobile euthanasia services around the world. According to online directory In Home Pet Euthanasia, nearly 600 mobile services have been listed since 2009 as providing home euthanasia services in Canada, the U.S., and England. Nearly 80 percent specialize in euthanasia work or the broader field of animal hospice, including euthanasia services. The shift toward home euthanasia is well-founded and necessary for many families. Pets feel safer at home. And for loving owners, being at home for their pet’s euthanasia provides them privacy and reduces the challenges of driving and interacting with others while in the midst of grief.

A good death is achieved by advocating for, and acting on, what is safest for the pet and what is most meaningful for the caregiver.

Home euthanasia has proven extremely rewarding work for those who offer it. It’s also gaining in popularity, with one service reporting its team of veterinarians assisted upward of 50,000 pets in the home setting in 2019. That’s an impressive number and indicates the trend of home euthanasia is here to stay.

Like any other progressive movement, advanced euthanasia did not happen overnight. And there are lingering obstacles that continue to stifle necessary change. Number one is the old paradigm that if it’s not broke, don’t fix it. It can be hard for veterinary teams to make lasting change around euthanasia. Reshaping a hospital’s culture takes time and commitment, but it can be done and done well.

Consider the following steps to create lasting change:

  • Dedicate one month a year to euthanasia-related discussions
  • Get everyone’s input on desired improvements
  • Create a euthanasia manual and refer to it regularly
  • Hold euthanasia rounds to review successes/challenges
  • Have multiple team members obtain advanced euthanasia training

These days, the veterinary profession recognizes the value of appropriate self-care. In this respect, self-care with regard to euthanasia begins long before the appointment. It is becoming standard practice to discuss a veterinary team member’s professional limits around euthanasia. North American Veterinary Community (NAVC) and the Human Animal Bond Research Institute (HABRI) human animal bond certification program focuses on this concept in its euthanasia module. It describes how veterinary teams should take time to determine who enjoys (yes, enjoys) euthanasia work, to write down how many euthanasias one can help in a day, week, etc., and how the team plans to practice self-care. Examples include team outings, fun food days, and setting limits on the amount of time worked in a day. The likelihood of compassion fatigue is high if care is not properly taken from the onset of euthanasia-related work.

As far as we’ve come, there is always room for growth. New techniques, improved euthanasia education opportunities, and better client support tools are on the horizon. We continue to hone our skills around gentle animal handling and pay increased attention to where we gather for euthanasia. This has never been truer than during the COVID pandemic. Veterinary teams have shifted the delivery of care, ensuring euthanasia remains an essential procedure. Creative approaches to preplanning, social distancing, technique selection, and appointment timing have played vital roles in protecting the human-animal bond. The veterinary profession dealt with these necessary modifications swiftly and compassionately. And it’s important to mention that while this article has been focused on euthanasia, death is a process, not always just a moment in time. Good death also refers to the meaningful journey leading up to death, be it natural or via active euthanasia. In the words of Benjamin Franklin, “Well done is better than well said.” To help the good death revolution flourish, we must act accordingly. A good death is achieved by advocating for, and acting on, what is safest for the pet, what is most meaningful for the caregiver, and what will nourish the veterinary team. If you haven’t already, how will you join the revolution?

Complete Article ↪HERE↩!

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Caring For The Caregivers

By Nekee Pandya

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Social Isolation a Threat to Hospice Patients During COVID-19

By Holly Vossel

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

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

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

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

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

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

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

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

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

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

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

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Don’t Grieve Alone. Reach Out.

Finding emotional support during a crisis often means turning to long-established networks already built for distance.

By Nicole Chung

In April, when my adoptive mother began to decline after months of battling cancer, I tried to show my love and let her know I was thinking of her through phone and Skype calls, gifts and handwritten letters. I was managing her finances and helping to coordinate her care, and often felt like I was having one long, sustained panic attack.

But friends kept vigil with me, lighting up my phone with support and listening when I called to vent or cry. Sometimes the distance made this easier — if I was awake and spiraling at midnight, I knew I could reach out to someone three time zones behind without waking them.

My mom died in May. Suddenly, I couldn’t bring myself to answer when people called to check on me. I didn’t understand why. Perhaps I would have felt hesitant to beg for support, given that everyone I knew was exhausted and overwhelmed by the ongoing pandemic, but these people were reaching out to me — why was I abandoning the communication that had been my lifeline for weeks?

A few days after my mother’s death, another friend called, and as I stared at the screen I realized that I felt nauseated; my heart was racing. I had developed a sense of deep anxiety about the phone because, for weeks, it had been my conduit for receiving and passing on gutting updates. Because I did not want to say the unthinkable words — “My mom is gone” — to even the most sympathetic listener. Because no matter how often the phone rang, it would never again be her.

One of the cruelest realities of this pandemic is that it has deprived so many of us the opportunity to grieve in the most familiar, instinctive ways. We can share stories, cry and laugh together over Zoom, but we can’t simply sit in quiet companionship or hold each other when words fail us. After my loss, I ran out of words to share; I couldn’t imagine calling anyone. How was I going to feel connected to others, find comfort and strength in my friends?

People near and far began to send sympathy cards, flowers, snacks, gourmet ice cream. My biological sister couldn’t be at my side as she was when my adoptive father died, but she checked in often and sent me soup and socks. One person gave me handmade jewelry in my favorite colors; another mailed a magnolia tree I could plant in my mother’s memory.

My friends Jasmine and Reese organized a group to record video condolences — a virtual shower of compassion and care — and, with tears rolling down my face, I played and replayed the messages, feeling held in the love of my friends and recognizing a clear invitation to reach out for more support when I was ready.

As it turned out, socially distanced grieving didn’t mean grieving alone — so many people found ways to offer support, as if they knew what I needed even when I didn’t. It occurred to me that most of them hadn’t needed to dig deep in order to understand what I was going through.

“After a trauma, one of the lingering shocks can be the feeling of aloneness that follows,” Juli Fraga, a psychologist, told me. “In this pandemic, that sense of aloneness might be softened because of our collective suffering — everybody needs support right now.”

For many of us, finding emotional support often means turning to long-established networks already built for distance. We may be weary or fearful now, freshly cut off from familiar routines and many forms of in-person support, but there’s still reassurance and solace to be found in distanced fellowship.

“At moments of peak fear and distress, we all think of connection and reaching out to people we love,” said Joy Lieberthal Rho, a social worker and therapist. “It’s part of that mass moment of reckoning in a crisis.”

As the pandemic drags on and our emotional reserves dwindle, we’re still doing our best to care for loved ones we can’t visit, sharing burdens, mourning losses, and celebrating tiny victories in long-distance communion.

Sometimes that means a call, just listening to and spending time with one another. Sometimes it means sharing resources or sending gifts, if we’re lucky enough to be able to do so — as my friend Jess put it, “Buying gifts for people who are going through hard times has been the only good thing this year.”

If you’re like me and have a hard time asking for help or naming what you need — especially now, when everyone you know is struggling — Ms. Rho suggests starting with “just one person who has been consistently good about reaching out” to you. “This gives that person positive feedback” for being such a good friend to you, she says, and perhaps they’ll be motivated to continue, or to let others know you could use extra support. Dr. Fraga says that asking for help can also give others permission to voice their own needs.

When it’s your turn to offer comfort or aid, Martha Crawford, a psychotherapist and licensed social worker, recommends asking yourself what is in your power to do and letting a loved one know that you have the emotional capacity to do it.

“With grief on this massive scale, we move through periods of time when we can function and periods when we can’t,” she said. “Try to honestly recognize where you are — when you have support to lend and when you have support to give — and then let people know where you’re at, and ask where they’re at.” She says this form of emotional resource sharing is in “the spirit of mutual aid.”

“It’s a little harder to make somebody feel they’re held in your care through electronic intermediaries,” Ms. Crawford added. “Maybe there is some pressure to try to offer more active support, suggestions or advice.” But the helping professionals I spoke with also pointed to the intimacy that can take root when we have a bit of physical distance, and at the same time get these powerful glimpses into each other’s homes and daily experiences.

“It can be hard not to meet face-to-face,” said Dr. Fraga, “but virtual meetings give me a new window into people’s lives, letting me actually see some of the things they’ve been talking about.”

At least once a day, you probably hear someone mention pandemic fatigue. The days seem endless, even as weeks fly by, and still there is no return to normalcy. Whatever it was that gave you strength or courage in the early days of the pandemic might be wavering now. Maybe you can’t bounce back so quickly. Maybe you shouldn’t — sometimes you need to stay down, take that extra breath, ask for help before you can figure out how to go on.

Whenever I rise and get back to it — to help my family, to do my job, to support my friends the way they’ve generously supported me — I often think of my mother, the person most responsible for showing me that love can defy distance and be an endless source of strength and resilience.

For decades, I watched her work hard to support us, care for her mother and my father, fight for her own survival and that of others. She believed in me so fiercely that I still feel her love and faith in the active, present tense, even though she is far beyond my reach. It’s that kind of support I want to extend to others now, sharing what strength and nourishment I can, even if I don’t know when we’ll share physical space again.

Complete Article ↪HERE↩!

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Dying in a Leadership Vacuum

Covid-19 has created a crisis throughout the world. This crisis has produced a test of leadership. With no good options to combat a novel pathogen, countries were forced to make hard choices about how to respond. Here in the United States, our leaders have failed that test. They have taken a crisis and turned it into a tragedy.

The magnitude of this failure is astonishing. According to the Johns Hopkins Center for Systems Science and Engineering,1 the United States leads the world in Covid-19 cases and in deaths due to the disease, far exceeding the numbers in much larger countries, such as China. The death rate in this country is more than double that of Canada, exceeds that of Japan, a country with a vulnerable and elderly population, by a factor of almost 50, and even dwarfs the rates in lower-middle-income countries, such as Vietnam, by a factor of almost 2000. Covid-19 is an overwhelming challenge, and many factors contribute to its severity. But the one we can control is how we behave. And in the United States we have consistently behaved poorly.

We know that we could have done better. China, faced with the first outbreak, chose strict quarantine and isolation after an initial delay. These measures were severe but effective, essentially eliminating transmission at the point where the outbreak began and reducing the death rate to a reported 3 per million, as compared with more than 500 per million in the United States. Countries that had far more exchange with China, such as Singapore and South Korea, began intensive testing early, along with aggressive contact tracing and appropriate isolation, and have had relatively small outbreaks. And New Zealand has used these same measures, together with its geographic advantages, to come close to eliminating the disease, something that has allowed that country to limit the time of closure and to largely reopen society to a prepandemic level. In general, not only have many democracies done better than the United States, but they have also outperformed us by orders of magnitude.

Why has the United States handled this pandemic so badly? We have failed at almost every step. We had ample warning, but when the disease first arrived, we were incapable of testing effectively and couldn’t provide even the most basic personal protective equipment to health care workers and the general public. And we continue to be way behind the curve in testing. While the absolute numbers of tests have increased substantially, the more useful metric is the number of tests performed per infected person, a rate that puts us far down the international list, below such places as Kazakhstan, Zimbabwe, and Ethiopia, countries that cannot boast the biomedical infrastructure or the manufacturing capacity that we have.2 Moreover, a lack of emphasis on developing capacity has meant that U.S. test results are often long delayed, rendering the results useless for disease control.

Although we tend to focus on technology, most of the interventions that have large effects are not complicated. The United States instituted quarantine and isolation measures late and inconsistently, often without any effort to enforce them, after the disease had spread substantially in many communities. Our rules on social distancing have in many places been lackadaisical at best, with loosening of restrictions long before adequate disease control had been achieved. And in much of the country, people simply don’t wear masks, largely because our leaders have stated outright that masks are political tools rather than effective infection control measures. The government has appropriately invested heavily in vaccine development, but its rhetoric has politicized the development process and led to growing public distrust.

The United States came into this crisis with enormous advantages. Along with tremendous manufacturing capacity, we have a biomedical research system that is the envy of the world. We have enormous expertise in public health, health policy, and basic biology and have consistently been able to turn that expertise into new therapies and preventive measures. And much of that national expertise resides in government institutions. Yet our leaders have largely chosen to ignore and even denigrate experts.

The response of our nation’s leaders has been consistently inadequate. The federal government has largely abandoned disease control to the states. Governors have varied in their responses, not so much by party as by competence. But whatever their competence, governors do not have the tools that Washington controls. Instead of using those tools, the federal government has undermined them. The Centers for Disease Control and Prevention, which was the world’s leading disease response organization, has been eviscerated and has suffered dramatic testing and policy failures. The National Institutes of Health have played a key role in vaccine development but have been excluded from much crucial government decision making. And the Food and Drug Administration has been shamefully politicized,3 appearing to respond to pressure from the administration rather than scientific evidence. Our current leaders have undercut trust in science and in government,4 causing damage that will certainly outlast them. Instead of relying on expertise, the administration has turned to uninformed “opinion leaders” and charlatans who obscure the truth and facilitate the promulgation of outright lies.

Let’s be clear about the cost of not taking even simple measures. An outbreak that has disproportionately affected communities of color has exacerbated the tensions associated with inequality. Many of our children are missing school at critical times in their social and intellectual development. The hard work of health care professionals, who have put their lives on the line, has not been used wisely. Our current leadership takes pride in the economy, but while most of the world has opened up to some extent, the United States still suffers from disease rates that have prevented many businesses from reopening, with a resultant loss of hundreds of billions of dollars and millions of jobs. And more than 200,000 Americans have died. Some deaths from Covid-19 were unavoidable. But, although it is impossible to project the precise number of additional American lives lost because of weak and inappropriate government policies, it is at least in the tens of thousands in a pandemic that has already killed more Americans than any conflict since World War II.

Anyone else who recklessly squandered lives and money in this way would be suffering legal consequences. Our leaders have largely claimed immunity for their actions. But this election gives us the power to render judgment. Reasonable people will certainly disagree about the many political positions taken by candidates. But truth is neither liberal nor conservative. When it comes to the response to the largest public health crisis of our time, our current political leaders have demonstrated that they are dangerously incompetent. We should not abet them and enable the deaths of thousands more Americans by allowing them to keep their jobs.

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Dramas discuss what makes a good death in the age of Covid

By Alex Spencer

The coronavirus pandemic has forced millions of us to come face to face with death in ways that we never imagined. Whether we’ve experienced personal losses, attended virtual funerals, or watched death tolls creeping up on the news, we are all confronting the pain of illness, death and grief and we’re having different kinds of conversation than we did before.

Researchers from the A Good Death? project at Cambridge University’s English faculty have teamed up with Menagerie Theatre Company to create three original audio plays, released online for free today (Wednesday) to help us to think and talk about this new reality. Written and recorded during lockdown by Menagerie actors, Seven Arguments with Grief, End of Life Care – A Ghost Story and A Look, A Wave are short 15-minute plays that provide glimpses into the thoughts and feelings of a bereaved mother and a hospital doctor, and reflect on the final farewell of the deathbed goodbye.

Written by Patrick Morris, co-artistic director of Menagerie, and inspired by the research of Dr Laura Davies into the history of writing about death, these plays don’t try to provide answers about how to handle what we’re all experiencing, in different ways, right now. What they do is capture personal stories and aim to be authentic to how hard life, death and loss can be.

Laura told the Cambridge Independent: “We have been running them since 2018 to improve conversations about death and dying using literature and the arts that means we run public events such as workshops for bereavement counsellors, people who work in palliative care, hospice workers and we use literature, museum objects and artworks to help people talk about death and dying.

“During the pandemic we built on an existing connection with Menagerie Theatre at the Cambridge Junction to think about how we could make some audio drama that people could listen to at home or on headphones that hopes, in a non-direct way, to help people to think about death and dying in a different way to the headlines of the death toll creeping up.

“We wanted people to think about what they believe and how they are feeling and what their experiences are. Right now we are all being forced to confront a reality that is universal but in a new way. Our ancestors would have been closer to death with it being more common for people to die in the home – child mortality rates were higher and plague and disease that couldn’t be controlled were more usual. We have been protected in the west from that sense that things are beyond our control and that we are quite vulnerable as human beings. You can’t avoid death and dying at the moment and many people are reporting feeling anxious about it, but of course you can’t hide.

“It’s important there’s a way to think about these ideas and listen to a story that can prompt reflections without increasing fear and anxiety. The work of literature and drama is to stimulate emotions,but with a bit of distance because you know it isn’t real. Our message is that death is part of life and that the way in which individuals experience life, death and loss is complicated and unique, andthat there is not a right or wrong way to grieve or a right or wrong way to live your own life knowing it will end.

“The more you talk about it doesn’t make it more likely to happen, but it can enhance the way you live.

“Even if there are elements of death and dying we can’t control, such as where and when and how we might die, it helps to have shared your wishes with your family and to have thought about what you might wish your legacy to be. They can help you to come to terms with it.”

A Good Death? includes workshops designed for practitioners, such as bereavement counsellors and hospice workers, along with public events, creative collaborations and online resources. The project also uses literature and the arts to open up new conversations about death, dying and bereavement.

Laura added: “One of the things emerging in terms of cultural impact is the experience of complicated grief that comes from a traumatic death. Early research points to the fact we are looking at long-term consequences for people’s mental health because they may have experienced not being able to be with a loved one at the end, or only being able to attend a funeral by Zoom. And missing out on those kinds of rituals makes it harder for people to grieve. Psychologists are looking at this cohort of bereaved people and the impact it will have on them.”

Menagerie is a new writing theatre company, resident at Cambridge Junction. It aims to develop and produce new plays which engage powerfully, imaginatively and critically with the contemporary world. Its co-artistic director Patrick explained: “There are so many books about the grieving process as if it’s some kind of logical process rather than something that’s actually faltering, that stalls, that destroys some people, but makes other people. I wanted to create a space for the real difficulties of grief.”

On the value of this collaboration, Laura added: “Working with Menagerie has given me a new perspective on my research into 18th century literature. These plays turn abstract and complex ideas into personal stories, showing new angles that I’ve not noticed before. And they capture brilliantly both how similar our struggles today are to those of the past, and how every person’s response to death or loss is unique.”

The plays can be listened to on the A Good Death? project website, good-death.english.cam.ac.uk/collab , where you can also watch interviews with the researchers, writer and actors.

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Covid-19 makes us think about our mortality. Our brains aren’t designed for that.

By Emma Pattee

You probably remember where you were that day in March when you first realized that the novel coronavirus was something.

Maybe you were chatting with co-workers in the lunchroom. Maybe you were browsing the news on your phone, seeing pictures of health-care workers in full protective gear like astronauts, or of older people with their hands pressed against their bedroom windows as their grown children clustered outside. Maybe you went to the grocery store and saw all the bare shelves where toilet paper used to be.

I remember where I was: driving to the gym for a Mommy & Me boot camp.

I pulled up to a red light and locked eyes with my 6-month-old baby in the rearview mirror. I felt unsettled and scared. I had an inexplicable urge to go home, and also to call everyone I knew and check on them. Yet nothing had happened. I was safe, healthy and employed. I was (and still am) more likely to die of a car accident than of contracting covid-19. It would be months before the state I live in, Oregon, would have a significant number of cases.

That eerie uncomfortable feeling has been described as grief. As fear. Or anxiety. But Sheldon Solomon, a social psychologist and professor at Skidmore College, has a more robust explanation: It is the existential anxiety caused by reminders of our own mortality.

Simply put, to function as a conscious being, it’s imperative that you be in denial about your impending death. How else would you go about the mundane aspects of your daily life — cleaning the gutters, paying the bills, sitting in traffic — if you were constantly aware of the inevitability of your own death?

“You would be overwhelmed with potentially debilitating existential terror,” Solomon said.

The logical outcome is a kind of cognitive dissonance. You know all humans die, you know that you are human, and yet somehow you don’t believe that you yourself are going to die.

Solomon and two other psychologists, Jeff Greenberg, a professor at the University of Arizona, and Thomas Pyszczynski, a professor at the University of Colorado at Colorado Springs, have spent the past two decades researching the ways in which humans avoid thinking about mortality and how we behave when we are reminded of death.

Death avoidance isn’t simply a psychological theory either; a neurological study was published in 2019 about a mechanism in the brain that avoids awareness of a person’s own mortality and that categorizes death as something unfortunate that happens to other people.

In other words, we are wired to accept that death happens — just not to us.

It’s easier to keep this denial going when death is not a part of your life. The more that death and dying become part of your daily experience — getting rear-ended on the freeway, the death of a loved one, a scary test at the doctor’s office, perhaps a global pandemic — the harder it is to maintain that denial. Greenberg, a co-creator of the Terror Management Theory, said that, in their research, they have found a few predictable but different responses to death reminders: an urge to make yourself feel safe (in the world of the coronavirus, that would look like wearing a mask or washing your hands), complete denial (deciding the virus is part of a conspiracy theory, or reminding yourself that nobody you know is sick or that you are young and healthy) or distraction.

Solomon said he is not surprised that during the lockdown rates of shopping, drinking and TV watching have gone up.

“What we are seeing is literally the predictable result of pervasive reminders of death,” he said.

An Israeli study showed some participants a flier about death anxiety and others one about back pain. When subjects were then offered an alcoholic beverage, one-third of the death flier group bought alcohol vs. one-tenth of the back-pain group.

The coronavirus pandemic isn’t the first time we’ve been reminded of death. In the past decade, hundreds of thousands of people have died of diseases, natural disasters and terrorist attacks, and many have experienced the loss of a loved one.

What makes this instance so unique is that many of us are stuck at home, our comfortable routines disrupted and our go-to denial tools such as the gym or the bar are out of reach. For those of us who have temporarily or permanently lost employment, our ability to block out death reminders is further reduced.

“When you have to go into lockdown to protect yourself from the physical threat, it’s interfering with those things that day-to-day allow us to feel psychologically secure in our sense of value in the world,” Greenberg said.

“When people are being laid off, and hours are being cut, they can’t provide for themselves and their families, they can’t do the things they normally do,” he said. “They can’t go out and have their value socially validated by friends and colleagues, then there’s a threat to that psychological security as well as a threat to physical safety.”

Additionally, the solitude that comes from being stuck at home may cause more than just a nagging, uneasy feeling; it may actually cause the acute realization of our own deaths.

James Baillie, a professor of philosophy at the University of Portland, believes the mechanisms that prevent us from fully grasping that we are going to die can temporarily cease to function, causing us to suddenly confront our own mortality, a fact we know but rarely acknowledge. Baillie calls this phenomenon an existential shock.

“Unlike covid[-19], the fact of our mortal nature persists throughout our lives, and we can do nothing about it,” he said. “We virtually never think about it, and, when we do, we pay lip service to it.”

Existential shock is what happens when we truly realize that one day we will cease to exist and the world will go on without us. Baillie theorizes that this shock can be brought on by moments of contemplation or a change in our routine.

“For some people, being confronted firsthand with the reality of covid[-19] deaths may cause existential shock, just as narrowly avoiding an auto collision might shock one into existential shock,” he said. “For others, the radical disruption of their daily lives can bring it on.”

Baillie describes this experience as similar to a panic attack.

Whether you are experiencing existential shock or just ongoing death reminders, it doesn’t need to be a wholly negative thing. Greenberg said that death reminders don’t necessarily cause us to change our behavior, they simply intensify our preexisting beliefs and behaviors.

“You get the worst and the best when death thoughts are close to conscious,” Greenberg said. “People want to feel that they’re a lasting contributor to a meaningful world so they’re going to assert that.”

Solomon pointed out that lab studies had shown that some people become more humble and grateful when reminded of their mortality.

Even if we don’t want to think about it every day, the occasional reminder of our own mortality doesn’t have to cause us paralyzing anxiety, or send us running to Amazon with a credit card in one hand and a martini in the other.

Solomon suggested an alternative way of thinking about mortality: “I am an infinitesimal speck of carbon-based dust born in a time and place not of my choosing here for an incredible brief amount of time before my atoms are scattered back into the cosmos. That need not be a terrifying thought.”

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