New York could soon become the sixth state to legalize the composting of dead people, a practice prohibited by Jewish law, but one which a small but growing number of American Jews have come to embrace.
Axios has called it “the hot new thing in death care.” For proponents, human composting aligns with an ecological mindset that sees human beings as part of nature, obligated to care for the Earth even after they die.
A shrouded mannequin lies near a composting vessel at Recompose, a Seatte funeral home specializing in human composting in October 2022.
Gov. Kathy Hochul has until Dec. 31 to sign a legalization bill into law. She has not yet tipped her hand on the measure, which passed both houses of the legislature easily. Several Jewish lawmakers voted for it.
Traditional Jewish burial, which calls for plain wood coffins, is considered relatively green. But human composting is touted as one of the greenest options available — there are no coffins to bury or bodies to burn.
Orthodox Jewish rabbis, however, hold that halacha, or Jewish law, clearly forbids human composting, for many of the same reasons it forbids cremation, which has overtaken traditional burial in the U.S. as the most popular option for American families after the death of a relative.
Still, Jews are beginning to consider and choose human composting, and say it can be done in keeping with their Jewish values. Recompose in Seattle is among several companies in states where the process is legal that have composted the bodies of Jewish clients. Some rabbis, from more liberal Jewish traditions, are willing to support the choice.
Rabbi Seth Goldstein of Temple Beth Hatfiloh in Olympia, Washington — the first state, in 2020, to approve human composting — has not yet presided at the funeral of someone who chose to be composted. But some of his congregants have asked about it.
“It is not something I was on the front lines for,” or for cremation either, said Goldstein, who was ordained in the Reconstructionist tradition.
But Goldstein is willing to work with those who favor composting, and said he would figure out ways to incorporate Jewish ritual into the funeral rather than to turn a family away.
“Human composting seems more in line with Jewish practice than cremation in terms of the practices and values that surround it,” he added. “It is something that has a lot of environmental value.”
From dust to dust
Anne Lang
Human composting — also called terramation and natural organic reduction — generally involves placing the deceased in a vessel, which can be cylindrical or boxlike, atop a bed of organic material — wood chips, alfalfa and sawdust are commonly used. The body is often wrapped in a cotton shroud, and air and moisture are pumped in.
Microbes found naturally in the body and the organic material take about two months to decompose it. What remains is about one cubic yard of soil and bones, which are then ground into a powder. Any medical devices or hardware is removed from the soil by hand.
Survivors can scatter the soil in a cemetery, their backyards or in a natural spot special to the deceased.
That’s what Anne Lang wanted.
“When it is my time, I would like to be composted,” she told her daughter Zoe. The Jewish woman from Boulder, who died of lymphoma in May, loved the outdoors and lived in Colorado, which legalized human composting last year.
At her mother’s deathbed, said Zoe Lang, the family said the Mourner’s Kaddish though they are not particularly observant. “It felt like something my mom would do and I wanted to honor her,” she said.
The funeral took place outside, with a view of the Flatiron rock formations. The Natural Funeral, a company not far from Boulder, took care of the composting. Two and a half months later, Anne Lang’s body was soil.
“The company asked if we wanted to pick it up and we chose to have it return to the Earth because that is what my mom would have wanted. So it was brought to a farm that grows flowers and trees,” Zoe Lang said.
The service cost the family between $7,000 and $8,000, and would have cost about $12,000 had they bought a coffin and a burial plot, Zoe Lang said.
It doesn’t bother her that she has no particular place to visit to mourn her mother.
“She is still with us,” Zoe Lang said. “I think she would be thrilled to know she is coming back as a flower or a tree with a beautiful view.”
More human composting businesses are opening as more states allow it. In addition to Washington and Colorado, it’s been legalized in Oregon, Vermont and California.
Washington has at least three such businesses — Recompose, Return Home and Earth, which promises a “carbon neutral alternative to cremation” and allows families to take a portion of the soil created from a body. It sends the rest to a land restoration project on the Olympic Peninsula.
Objections
Traditional Jewish burial forbids many common funeral practices that are also rejected by proponents of human composting.
A small box of soil made from human remains sits on a table at the Recompose funeral home in Seattle.
Jewish law, for example, prohibits embalming, a process that many who favor composting consider unnatural and polluting. And it shuns crypts, cement liners and other containers for the body, said Rabbi Avi Shafran, director of public affairs at Agudath Israel of America, the nation’s leading ultra-Orthodox umbrella group.
Cremation, which some environmentalists object to for the pollutants it produces, is also forbidden under Jewish law, which requires specific steps after a person dies that include the washing and quick burial of the body. In Orthodox tradition, cremation is a defilement.
But composting is similarly problematic, according to Shafran. “The idea of ‘utilizing’ a body as a growth medium is anathema to the honor due to a vessel that once held a human spirit,” he said.
Or as Rabbi Joseph Potasnik, executive vice president of the New York Board of Rabbis, put it: “Reverence for the dead through proper burial traditions has taken place throughout the generations.” He added: “The idea of grinding the bones is at odds with Jewish law.”
The Conservative movement, which lies between more traditional Orthodox Judaism and the more liberal Reform movement, has not taken a position on human composting, said Rabbi Jeremy Kalmanofsky, who leads Ansche Chesed, a Conservative synagogue in Manhattan. But he has studied the issue on its behalf and concluded that making a profit from human composting does not align with Jewish tradition.
“There is a difference between returning [a body] to the Earth — which is the point — and using the soil for a business,” he said.
A tallit atop a vessel that contains the remains of a Jewish person at Return Home, a Washington state funeral home that specializes in human composting.
In general, he continued, dead bodies shouldn’t be used for tangible benefit, even if it’s not strictly commercial. That’s why, he said, “it’s dishonorable to eat fruits or pick flowers growing directly above graves, nourished partly by decomposing human flesh.”
The Union for Reform Judaism, the largest Jewish denomination in the U.S., had no comment on human composting.
Goldstein, the Washington state rabbi who has fielded inquiries about human composting, is a past president of the Reconstructionist Rabbinical Association, which he said not taken a position on it.
But even though he’s not an advocate, Goldstein said for some Jews, human composting dovetails nicely with their Jewish environmental values, which call them to be good stewards of the Earth. He advises other rabbis to be prepared for the conversation.
“I have to serve my people,” Goldstein said. “This is not an issue we can shy away from. It is reality and we have to deal with it.”
My therapist told me she was dying the way someone else might admit to cancelling their gym membership. Oh no, she told me when I asked how her immunotherapy was going, she had stopped all that. She sounded regretful but not distressed. I was confused. I knew the tumours in her lungs were inoperable but I had understood the cancer was all but beaten. I’d asked how the treatment was going only to check she wasn’t suffering any nasty side-effects.
Actually, the chemotherapy hadn’t worked and the immunotherapy was somehow making things worse. She had been offered another treatment but that would mean losing her hair and she would rather not. So no, she had given everything up except the oxygen.
“Porca,” Sara said, summarising the situation in a succinct Italian expletive, and I slowly understood that one of my favourite people on Earth was dying.
“I love life but if it’s destiny, I don’t mind to die. I think it’s an injustice but I say, Sara, care less for once!
“I believe in a miracle. I want another year, maybe they’ll give me another few months, it doesn’t really matter. I’m feeling quite well actually!”
In fact, we had two months. Rather than cut down on our sessions she upped them, refusing to accept any additional payment, and miraculously this was somehow enough time for her to teach me how to live without her and how to die excellently.
“Dai, come on then, we’ve a lot to do. We need to close properly, and you need to have a baby before I die. Concentrate on making love!”
She was joking. Sort of.
“By the way, do you happen to know someone who can talk French with me? Someone nice and friendly. I need to practise my French for paradise.”
If the boundaries of a conventional client-therapist relationship sound as though they were blurred in her last weeks, they weren’t. At least, not unintentionally. Sara was unorthodox, certainly, but mostly she was cunning; she had a plan.
I found her in November 2018. I had been driving up a steep mountain road on a Greek island on holiday when I started to sweat profusely from my palms. I didn’t trust myself not to swerve over the edge. My whole body started to shake, then I couldn’t catch my breath, then I was going to black out, but there was nowhere to pull over. The roads were narrow and there was a precipitous drop inches from me, so I thought the safest solution was to drive at a crawl on the wrong side of the road, clinging to the mountainside. The trucks driving towards me in the same lane, horns blaring, swerving to avoid me, did not agree. When I finally reached flat land at the top, I stopped, got out and dropped to the ground, needing to press my belly to the earth like a snake. I abandoned the rental car and walked 35km to a port where I hitched a lift back to my Airbnb on a fishing boat. Then I Googled therapists.
One of the first results promising swift treatment for panic disorders was Sara Dryburgh, a clinical psychologist and psychotherapist with 30 years’ experience.
A few days after flying home, I am in the consultation room at her home in north London. A very tiny woman, maybe 50 or 60 years old, with a huge smile, red lips and excellent hair sits on the sofa opposite me, in a glamorous silk shirt, covered in blankets. I am also covered in blankets and wearing the fluffy slippers with dog faces she has offered me. The room is messy, littered with open books, mostly on myth and philosophy, mostly Italian; postcards; stuffed toys and trinkets. It’s totally mad.
Sara Dryburgh in Verona in the late 1980s.
I tell her that my panic attacks had started when I was six and first understood that I was going to die. They have never really left, just shifted about. Since Greece, they have focused mostly on roads. Driving along any road with a drop, I can black out with terror.
“Yes, the panic is there to tell you something,” Sara says.
She doesn’t want to talk much more about why. She suggests instead that we try a guided meditation and uncomfortably, I agree. Surely reading a meditation from a book is something I can do without professional assistance. Still, I close my eyes and concentrate as she reads in her thick Italian accent. I miss every fifth word.
“You find yourself by a beautiful something. By the something you feel yourself very calm.”
I don’t know how, but it works. When we finish, I feel calmer than I can remember feeling. Or is it safer? In the course of the next three and a half years, I speak to her almost every week and my life changes completely for the calmer and the safer. I quit my job as an editor at the Guardian, move to Greece, and finally recover from a drawn-out, tumultuous breakup. We keep up our sessions by phone. Occasionally she speaks to me in Italian, refusing to accept that I can’t understand.
“Dai! Come on, it’s so easy. You’d learn it in a few weeks if you tried, and then you could read my Morelli!”
In clinical terms, Sara is a Jungian existentialist. Up there with Carl Jung, Aristotle and Melanie Klein is her all-time favourite Italian psychiatrist Raffaele Morelli. I can’t find any of his work in English, but Sara doesn’t see language as a barrier to anything.
“You know Morelli – nothing is just one thing,” she says, as if I’d read every word.
She had started her career as a child psychologist in Verona but her first job in adult psychotherapy was at St Thomas’ hospital in London where she proved to be an extremely effective talking therapist, despite not speaking a word of English. By the time we meet, she has developed her own unique vocabulary.
“Don’t be a fascist! Always so extremist. You need to find a quotidianity,” she tells me.
Quotidianity is not a word, at least not an English one, but I understand immediately what she means. Equilibrium. Easiness. Normality.
“It’s sad, yes, but let’s find the good augit,” she suggests inevitably.
The good augit – also not a word – is the heart of Sara’s ideology. She created it, then embodied it. I had always heard it as some Italian variation of augur: that augurs well, there is an augit. It’s only when she’s dying that I finally ask her what she’s actually saying. Is it object?
“No! Not object. Augit. It means to be able to stay with the good bit of your life. To stay with the good augit is to find the good in an experience,” she says.
“If you don’t have this capacity to take the good augit, then you are trapped.”
Her dying is a crash test for the augit theory. I find myself walking through beautiful Athenian parks crying because I can’t focus on anything other than this feeling of crushing grief. There is an odd sensation of psychic bones being broken and reset. Sara understands this without me having to tell her.
“In this last period, I’ve never learned so much, it’s unbelievable. And you are doing the same. Maybe we are sharing because it’s like the both of us, in a different way of course, are being reborn,” she says.
“I will be reborn as an angel and you will be reborn as a different part of you.”
She has already given me several Lamy fountain pens, all with green ink, and packs of small black notebooks. Now she tells me she wants me to write about her. “Yes! I value myself. I think I did plenty, I deserve a good closure, or no? Write about Sara, ‘I never met somebody so mad, she is dying,’” she laughs. “I thought that, at my funeral – I will be dead – I want you to be there. It would be nice having you as a journalist.”
The absurdity of inviting someone to her own funeral makes her laugh so long and hard, it triggers a coughing fit, and she has to call me back. From this point on, I start to record all our sessions so that I can write about her more accurately, and Sara sets about heroically dying according to the good augit principle.
She has never learned so much, she says repeatedly and in awe. When I ask her what it is she has learned exactly, she always tells me a story about someone else.
In February, Sara is admitted to hospital with what I think is pneumonia. In fact, doctors have given her only a week or two to live. The room has a beautiful view over London, she tells me from her hospital bed, and all the nurses are kind and brilliant. One in particular fascinates her: she has three children but they live with her parents in Africa while she earns enough money to support them. Sara, a mother of three, sees this as superhuman.
“She is an excellent nurse, excellent. If I call her, she is able to forget everything and concentrate on the illness, yet at the same time, she is always thinking about these three children,” she wonders in amazement.
“I think there are periods in life when you can do things that are impossible. Morelli is right – in our mind there is not only negative, we have resources.”
The Italian physiotherapist who comes to treat her at home when she can no longer move easily is a genius. He knows instinctively that distracting her with stories from his childhood is the only way to help her through terrifying fits of breathlessness so he can work on her enough to get her diaphragm functioning again.
Then there is the reflexologist, she tells me, who comes to see her every morning and makes her laugh. She is so talented, also a language teacher and a makeup artist, and so strong.
“Oh my lord, how can they do it? It’s a distraction, but I’m genuinely interested,” she says when I ask her how she can be so totally absorbed in the lives, problems and abilities of everyone else when her own is ending.
“It doesn’t make sense to spend the last few months of your life in mourning.”
She can no longer do most of the things that had always brought her joy – cycle to London Bridge, go to Vivaldi concerts at St Martin-in-the-Fields, visit the National Gallery, walk on Hampstead Heath – but dying hasn’t robbed her of pleasure.
“I’m treated as a queen! I have a massage on the feet, I have physiotherapy. If I knew I would be spoiled like this, I would have got ill before,” she cackles down the phone in mid-July, breathing audibly through her oxygen mask.
She loves delicious food, her middle son is a brilliant chef, but her body now refuses to digest it and she’s losing a lot of weight. She has the bikini body she always wanted. “You know Italian women, they need to be perfect. I couldn’t care less. I always bought these very small bikinis with this big stomach.
“I told my friend in Italy I need to have a few bikinis. She says, ‘But Sara, you don’t come to the sea!’ I told her, who cares? I need a new one – I will wear it in bed. I want to have it before I die.”
When Sara was four, she had pneumonia. Then she contracted rheumatic fever. Her uncles would wake up at 4am and take her to the sea, believing the water would strengthen her. Her sister had died with pneumonia aged two, and Sara attributes her own survival to the sea. It feels as though it might deliver her the same miracle again, if only she could reach it.
“Mamma, I do miss the sea,” she admits later in July when it’s 40C in north London.
“I really believe in nature. We should treat nature well because we have more than one family; we are also all children of nature and the cosmos.”
Her beliefs are more ancient Greek than flower child, and they help me. Dying becomes less terrifying when it’s less a brutal cessation of being and more a return to some original state with your meta-family: Mother Gaia, Father Uranus and Grandma Chaos. I find the idea reassuring, particularly if Sara is floating about in there somewhere.
The last photograph taken of Sara Dryburgh, five days before she died.
It’s about this time that I start hugging trees. I do it in the park near my house when I’m sure no other park walkers can see me. It’s a connectivity thing and it also helps. Maybe parts of Sara or me will be tree someday. I don’t tell anyone but her.
“You’re very clever to find parents in nature,” she congratulates me. “Your father is probably a tree, a birch or something similar.”
She bursts into song, offering in four perfect lines an animist’s answer to death anxiety: “Phoebe’s the sun / Phoebe’s the sea / Phoebe’s Phoebe / And is like a tree.”
For Sara, it’s the sea with its endless horizon that connects her to the infinite, the divine, the cosmos. It’s why her reliance on oxygen tanks is so difficult. She can no longer travel farther than an hour from home without panicking that her supply will run out. She will never see the sea again.
As the summer’s heatwave rolls on, she isn’t able to leave her third floor flat and breathing has become more difficult. One night, she almost dies. “At this moment, I really wanted from the heart the sea when it’s in a tempest, a rough sea. I have a friend who is teaching art and I just said to her, ‘Do you mind to send to me some rough sea?’ She sent me so many. Now I have the sea tempesta everywhere, it’s amazing!”
Somehow, for her, a symbol can fill any lack. She surrounds herself with paintings of the sea and fresh-cut roses. “I’m getting fixated on roses. I’m a rose fascist, I can’t have any other flower around me,” she tells me. “I only realised today it’s because the rose belongs to Italy. Also in England, there are roses everywhere, so in this moment when I can’t go to Italy, they are my roots.”
In early August, I fly back from Greece to see her. She looks thin but beautiful, full of energy, dragging her oxygen tank behind her like a bunch of balloons. I bring her pink roses and a wooden carving of a saint from Athens. The Greek Orthodox are very specific and the lady in the shop had recommended Savvas, a saint who specialises in miracles for people with lung cancer. Sara is delighted and we prop him up against the vase of roses, next to pictures of her sons, so she can see him from her chair.
She has a present for me, too: a pair of her silver starfish earrings.
“Just keep it. I want you to have something, for heredity,” she insists when I try to refuse. “Che bella, and they represent the sea.”
We talk a bit about her childhood and she tells me that, in the past few weeks, she’s been comforted by her sister.
“I contact her symbolically. She died but I have her inside myself,” she says with a shrug.
We finish the session by finding three good augits. Afterwards, she asks me to help her organise the presents she wants to send back to the little seaside town in Tuscany where she spent almost every summer. She won’t make it back again. A woman there had a miscarriage and local busybodies have been gossiping, saying it’s because she went out dancing that she lost the baby. Sara’s furious.
“What can I do? She doesn’t need a psychotherapist, so I got her all the girly bits. What does it take me? A few minutes, nothing.”
But she’s also bought presents for everyone in the town – books, toys, candles. I survey the haul, it looks like Santa’s sled, and tell her that she’s been very generous.
“Believe me if you’re generous it comes back,” she tells me. “Look at me! It comes back in so many things, unbelievable.”
I’ve been worrying for weeks about saying goodbye. What if it’s the last time I see her? It will be too painful. But when it comes to it, I feel warm and happy as I usually do after an hour in her company. I’m convinced she has longer than the doctors are allowing. They don’t know her. She has the sea, Saint Savvas, the cosmos. She’ll die when she’s ready.
“When do I see you next?” she asks as I head out the door, and I tell her I’ll be back in London in September.
“That’s nice,” she says. “I’m better. I think I will be alive. Go and enjoy, have a nice time. You can’t do things without risk!”
Over the next two weeks, our sessions are disrupted because I’m travelling, having a nice time. When we speak again, I’m back in Greece and Sara sounds frail. She doesn’t seem to be sleeping much any more but she’s been using the time alone at night to think and write. She studied philosophy before psychiatry and has composed poetry since she was a child. She has written her rules for a good life and asks if she can read them out to me. The effort is audible.
1 Balance: not putting all your effort into just one thing like professional success or accumulating wealth. 2 Honesty: being honest with yourself; not accepting comfortable lies. 3 Cherishing relationships with people who matter to you. Accepting that some people will never like you. 4 Developing your life to make best use of your own unique talents and attributes even when the result is not what society values the most. 5 Knowing when to give up on a lost cause. Accepting the inevitable with dignity. 6 Consider reading Marcus Aurelius’s Meditations and Edith Hall’s Aristotle’s Way.
I write them up, print them out and stick them on the wall next to my desk. I buy roses for my flat. I order a copy of Aristotle’s Way. When I next speak to Sara, it’s 16 August. She’s had a couple of difficult nights, she admits, but says she managed to get through them using mythology. “I’m incredible with myth, it’s Jung basically. I always go to Apollo. I decided to do a contract. I said, ‘Apollo, come on, give me a few months. I need to finish my clients properly.’ He hasn’t answered me yet what he wants back. What can I give back to Apollo? I need to think about it.”
I tell her I’m considering getting a tattoo of a rose because it reminds me of her, but she doesn’t like the idea at all. Why would I put myself through that sort of pain? I tell her that I love her.
“I think I represent a safe part and you have that inside you,” she tells me.
“I am ready for everything because I have an excellent life. I adore my clients. I did an excellent job. I really like my children and my husband. I couldn’t have more. Seriously! If I need to go, maybe it’s better that I’m the first because I have all this romantic theory to help me. I’m not worried about it at all, but I don’t want pain. This is it – I don’t want too much pain.”
She asks if we can speak for shorter periods but more often because talking for an hour is just too much. It’s Wednesday and we agree to talk again on Saturday. On Saturday morning, I receive a text from her number saying that she’s been taken ill. It doesn’t sound like her. It isn’t. Sara died on Friday morning.
Her memorial is held exactly one month after her death. It’s at the restaurant where her son is a chef. I wear the earrings she gave me, as I do when I want to feel close to her, and red lipstick because she would have liked it. Like almost everyone else, I’ve come with roses.
There is a board of pictures: Sara as a young girl looking adorably severe at her first communion; as a mother hugging her young sons; a toddler in the sea; a wife, her husband’s arm around her by a full rose bush. In front of the picture board is a spinning globe dotted with places she visited; her glasses; Savvas the Greek saint. I sit opposite the board next to an Italian woman. Like me, she is writing in a black notebook with a Lamy fountain pen with green ink. We notice and laugh.
Her husband and three sons speak. I wonder if they find it difficult facing a room of strangers in tears when they’re the ones who lost their wife and mother, but they are kind, curious and generous. They talk about Sara with a frank emotional intelligence that’s breathtaking. Her eldest son admits he had been having a hard time accepting that she was going to die. “I told Dad I was feeling very bad and he said, quite rightly, ‘You realise your mother has been sitting in a chair for two months doing nothing but scheming to make sure you’re going to be all right, so trust her.’ And I do. She was sneaky.”
Her middle son tells us they were all with her when she died.
“The nurse was administering the end-of-life care, all the drugs that meant Mum could have a peaceful end, comforting Mum, saying, ‘You’re doing really well, Sara, really well, that’s good, good, good.’ The last thing Mum did was to turn around and with great effort say, ‘I’m not doing good, I’m doing excellent.’
“That was her outlook. To look all the crappy stuff in the face and be like, nah, you’re all right. I see you’re there but I’m choosing to enjoy this more than I’m meant to. That ability to sing and dance no matter how shitty the situation and decide: no, I refuse to have a bad time here. I’m going to look at life and find it beautiful even if it sucks, and it really sucks at times. We should all remember that. We can all live excellently, not just fine.”
Her husband tells Sara’s clients that she has made arrangements for all of us who wanted to continue with another therapist, but repeats for us what he had told his son:
“If you feel lost, I would urge you to consider that she took great care in her last few months when she knew the end was near to prepare everyone, whether they were patients, friends, family. If you want her monument, look inside you.”
Back in Greece, I go to an island with some friends. I want very badly to be near the sea and Ikaria is one of the few Greek islands with proper waves. I want to learn to surf. It’s only on the drive from the ferry to the hotel that I realise the island is basically one huge mountain lined by terrifying cliffs. I consider getting straight back on the 12-hour ferry to Athens. I’ve never seen roads like them, not one bend without a dizzying drop to certain death. It’s fine, I tell myself, sweaty palmed. I’ll stick to surfing and hiking, writing and drinking.
On the second day, I sprain my ankle. If I want to do anything for the next week beyond sitting at the hotel bar, deathly cliff roads will be unavoidable. I’ve been listening to the recordings of my sessions with Sara. Her voice is clear in my head, or it’s my voice, I’m not sure.
“Dai, come on,” it says. “Fuck it, care less for once. Have fun!”
The road leading to a secret beach we’ve been told about is a dirt track edged by a sheer rock face that plunges to the sea. My friend negotiates it carefully and I peer out of the passenger seat window over the edge. I’m ready for the cold sweat, the hyperventilation, the blackout. It doesn’t come. At the bottom, we find one of the most beautiful coves any of us have ever seen. I hobble towards the water, nothing but tree-lined cliffs and a deep blue horizon in front of me. The sea tempesta, I think. It is a very good augit.
— It can be difficult to know exactly when someone is going to die, or has died. This page details some of the most common signs.
The following symptoms are often a sign that the person is about to die:
They might close their eyes frequently or they might be half-open
Facial muscles may relax and the jaw can drop
Skin can become very pale
Breathing can alternate between loud rasping breaths and quiet breathing.
Towards the end, dying people will often only breathe periodically, with an intake of breath followed by no breath for several seconds. This can be upsetting to witness as the person seems to stop breathing only to start again. There might be one or two last gasps a minute or so after what seemed like the last breath, before breathing eventually stops.
When someone dies
The moment of someone’s death is often very profound, even when you have expected it for a long time. You might want to talk to someone or call family and friends to let them know. You might prefer to be alone.
Some people feel overwhelmed with sadness, for others it can take days, weeks or months to process how they feel.
If you have been caring for the person you might feel exhausted, and the relief and finality of the moment of death can take you by surprise.
Every person’s experience of dying and bereavement is unique. However you are feeling, there are organisations and resources to help you. If you think you could benefit from bereavement support visit our page on how to find bereavement services.
All humans experience loss. This loss can include the death of a partner or spouse. Grief inevitably follows during the bereavement period. What is not commonly talked about is the reality of sexual bereavement. When a long-term sexual partner dies, so does one of the most pleasurable features of that connection.
For many, life brings love and sexual intimacy with a special someone. Illness and death require us to experience the journey of grieving. Responses to grief are as unique as each human fingerprint, but we all share some commonalities. The model of the 5 stages of grief, outlined in 1969 by Dr. Elizabeth Kubler-Ross, is well-known for normalizing what humans encounter over time after a loss.
What is sexual bereavement?
What isn’t so recognized is what is known as sexual bereavement. This is the grief that relates to losing sexual intimacy with your long-term spouse or partner. It may come after the death of the loved one. It can also begin before the loss as their health declines.
Our sex lives are private matters. When we subsequently feel deep sadness when our life companion dies, identifying the loss of the profoundly close sexual attachment once shared can be difficult. In addition, older adults statistically lose their spouses at a higher rate than younger age groups. Sexual bereavement, in turn, is a part of grief seniors may not be talking about.
What we know about sexual bereavement
Research in the area of sexual bereavement is sparse. In 2016, the term was coined in a small study of 104 older women, calling it “disenfranchised grief.” This seems to be the only formal study on what seems to be a common occurrence after loss.
One conclusion noted in this peer-reviewed research is that people aren’t talking about sexual bereavement because, as a society, we don’t recognize that older adults are sexually active beings.
What are the barriers to the discussion?
Baby Boomers are starting to shine a spotlight on the fact that seniors do have sex. The old media image of the asexual elder is giving way to a more accurate one of the sexually active senior. Scientific research is now following suit.
Previous sexual wellness studies typically had an age range that did not include those over the Medicare benefit age. Times are changing for the better as evidenced by the increased numbers of sex studies embracing the older population.
Another reason sexual bereavement isn’t commonly spoken about is that sex is an intimate topic. Older adults tend not to talk to their primary care providers about it, and primary care providers typically don’t ask.
Given that professionals are hush-hush about sexual wellness, how safe do you feel in sharing about the loss of sex in your life with your family or friends?
Until recently, research and discussions have primarily focused on a married, heterosexual experience of sex and the loss of intimacy after a death. If an individual is cohabitating or LGBTQ+, and possibly polyamorous as well, there is virtually no relevant public dialogue with which to relate. Any combination of these barriers can be devastatingly isolating.
You are not alone
Sexual bereavement is a legitimate grief response. Nowadays more people are saying it out loud. With the accessibility of the internet, personal story blogs and virtual support groups specifically addressing sexual bereavement are growing in number. Book publishers are giving voice to older authors telling their stories of love, sex, and loss.
Am I normal?
Because grief and bereavement are complex journeys, responses and behaviors can manifest in ways that may be uncharacteristic of one’s baseline personality. Grief tends to undermine decision-making processes and warp the sense of normality.
For instance, grief can pour water on all sexual fire an individual usually has. Energy typically spent in intimacy is now being rerouted to the hard emotional work during bereavement. So, while sexual bereavement is there as an emotional reality, physical sex drive may be absent.
Another authentic possibility within grief is a noted increase in sexual desire. This can be extremely shocking when a long-term sexual partner is gone, and one is left feeling a strong need to connect sexually.
According to science, it can be normal to feel the need to fill the void left by loss with sex. Orgasms and physical touch typically increase dopamine levels in the brain which elevate optimism and calms the nervous system. Oxytocin, the so-called “love hormone”, is also found in the intoxicating hormone cocktail produced with sexual pleasure. It stands to reason that having a rise in libido is the body’s way to seek pleasure when grief brings little.
Steps for healing
Accept your feelings around loss of sexual intimacy as both normal and appropriate.
If your sex partner is still alive but is unwell and unable to perform sexually, talk to them and find other ways to support intimacy.
Don’t compare your loss and bereavement to others.
Allow for time to grieve without outside timetables or agendas.
Identify one close person in your life with whom you feel safe and talk about your sexual loss.
Seek professional grief counseling or a grief support group, either online or in person.
If you experience physical sexual dysfunction during your bereavement, speak to your primary care provider. What may seem a normal part of grief may be a treatable medical issue separate from the grief response.
Grief and clinical depression are not the same. Speak to your primary care provider if you suspect mental health changes.
Grief is a complex human experience; so is sex. Sexual bereavement may arrive and complicate the process further. With gentle acknowledgment and conscious processing, this too may be overcome. Remember, you’re not alone in your natural human grief journey.
Many pet owners know that our connections with animals can be on an emotional par with those we share with other humans – and scientific research backs this up.
The key ingredients of human attachment are experiencing the other person as a dependable source of comfort, seeking them out when distressed, feeling enjoyment in their presence and missing them when apart. Researchers have identified these as features of our relationships with pets too.
Researchers have also found our connections with our fluffy, scaled and feathered friends come with a price, in that we grieve the loss of our pets. But some aspects of pet grief are unique.
Euthanasia
For many people, pet death may be the only experience they have of grief connected to euthanasia. Guilt or doubt over a decision to euthanise a cherished companion animal can complicate grief. For example, research has found that disagreements within families about whether it is (or was) right to put a pet to sleep can be particularly challenging.
But euthanasia also gives people a chance to prepare for a beloved animal’s passing. There is a chance to say goodbye and plan final moments to express love and respect such as a favourite meal, a night in together or a last goodbye.
There are stark differences in people’s responses to pet euthanasia. Israeli research found that in the aftermath of euthanised pet death, 83% of people feel certain they made the right decision. They believed they had granted their animal companion a more honourable death that minimised suffering.
Pet grief can make people turn inwards.
However, a Canadian study found 16% of participants in their study whose pets were euthanised “felt like murderers”. And American research has shown how nuanced the decision can be as 41% of participants in a study felt guilty and 4% experienced suicidal feelings after they consented to their animal being euthanised. Cultural beliefs, the nature and intensity of their relationship, attachment styles and personality influence people’s experience of pet euthanasia.
Disenfranchised grief
This type of loss is still less acceptable socially. This is called disenfranchised grief, which refers to losses that society doesn’t fully appreciate or ignores. This makes it harder to mourn, at least in public.
Older people often more isolated which makes their pets an important source of comfort.
Psychologists Robert Neiymeyer and John Jordan said disenfranchised grief is a result of an empathy failure. People deny their own pet grief because a part of them feels it is shameful. This isn’t just about keeping a stiff upper lip in the office or at the pub. People may feel pet grief is unacceptable to certain members of their family, or to the family more generally.
And at a wider level, there may be a mismatch between the depth of pet grief and social expectations around animal death. For example, some people may react with contempt if someone misses work or takes leave to mourn a pet.
Research suggests that when people are in anguish over the loss of a pet, disenfranchised grief makes it more difficult for them to find solace, post-traumatic growth and healing. Disenfranchised grief seems to restrain emotional expression in a way that makes it harder to process.
Our relationships to our pets can be as meaningful as those we share with each other. Losing our pets is no less painful, and our grief reflects that. There are dimensions of pet grief we need to recognise as unique. If we can accept pet death as a type of bereavement, we can lessen people’s suffering. We’re only human, after all.
Everyone has had a dream about dying at least once. Regardless of the cause of this dream about death, the whole concept of dreaming of dying is one of the most common nightmares people have.
Oddly enough, it’s also one of the most perplexing scenarios out there. But, believe it or not, dreams about dying don’t always imply death in a literal sense.
What does it mean when you dream about death and dying?
While dreams like this don’t mean you will die in real life, these dreams could mean a bunch of different things, all depending on the circumstances of the dream itself.
And despite feeling pretty ominous, many cultures believe that randomly dreaming of your death could be a sign that your death has died. In other words, it could be a sign that your fate changed for the better and that you’ll live a longer life.
In general, a dream about dying and death symbolizes inner changes, transformation, anxiety, discovery and positive development, and a fresh start. These dreams symbolically also relate to fear of the unknown, built-up resentment, grief, and trying to cope with your own mortality.
Death is a heavy subject, and it’s one that can take a lot of forms. For many people, death shows itself as a major loss. When we say something inside us died, we mean that it’s gone for good, and it’s rarely ever meant in a good way. As a result, a lot of the psychological dream interpretations about dying often will reflect this.
In many cases, having a nightmare about a family member, spouse, friend, or child dying can mean that you are afraid of losing them. It can also suggest that you may be harboring anxiety about the way they are changing, suggesting that you want them to remain the way they were when you first met them.
But there are also rage-related reasons why you might be dreaming about dying, too. Dreams of people dying can also suggest underlying anger or disappointment in some aspect of life. (It’s not unheard of, for example, for people who were victims of abuse to have dreams of their abusers dying pretty gruesome deaths.)
In some cases, dreaming of your own death could also be your brain’s way of giving you a metaphor for the way people abused you. People who are mistreated by others often will have dreams of themselves dying as a result of feeling useless or emotionally destroyed.
Above all, most dream analysts tend to see death dreams as a sign of confronting change.
The only thing that remains constant in life is change — and that might be why common dreams involve dying. This type of dream often represents a very final end and a brand new beginning. If you have recently undergone drastic changes in your life, this is the most likely reason why you’re dreaming of dying.
Adds Greg Mahr, MD, psychiatrist, author of “The Wisdom of Dreams,” and director of Consultation Liaison Psychiatry at Henry Ford Hospital in Detroit, “Dreams about dying are usually not literally about you dying; they are about an aspect of yourself dying, perhaps even an aspect that needs to die.”
The best way to figure out what your dream means is to take a look at your life to get a clue about what it could be. Death dreams often come as a result of having some tumultuous events in your life or are due to anxieties that could be causing you emotional distress.
Each dream is different, so it’s worth trying to figure out what the dream’s symbolism means to you.
What It Means If You Dream About Yourself Dying
Some people tend to have recurring dreams or nightmares about their own death. And while it can be a bit scary, this dream is actually a sign of change in your waking life.
This transitional phase will help you redirect your energy source and focus it more on your own mental health and well-being, rather than wasting it on others while neglecting yourself.
What It Means If You Dream About A Parent Dying
Generally, a dream about a parent dying acts as a wake-up call to focus your attention on how you approach life. This dream also indicates that you are experiencing stress and need to find a way to lessen it.
Dreaming about your father dying means you’ve been holding back from expressing your emotions, or that you are entering a new phase of the relationship with your parents, one based on comfort and support.
Dreaming about your mother dying relates to personal transformation, your own indecisiveness, or even missing a motherly figure in your life.
What It Means If You Dream About A Sibling Dying
Any dream about a loved one dying can be horrifying, and that’s especially true if you dream of a brother or sister passing away.
A sister dying in your dream indicates that you may have personal conflict with your close friends or family in real life, and need to take steps to remedy the situation.
If you dream of a brother dying, it is symbolic of the “death” of a brotherly friendship in your life, so it’s important to consider how you may be neglecting your friendships and, as a result, letting them die.
What It Means If You Dream About A Pet Dying
We all wish our furry friends could be with us forever, but part of owning a pet is realizing their mortality.
To dream about a pet dying relates to your desire to be a child again, not having to deal with the constant changes and responsibilities of adulthood. This dream can also indicate your need to step out of your comfort zone and try new things to become a more well-rounded person.
What It Means If You Dream About A Friend Dying
To dream about a friend dying indicates that you’re experiencing a change in a real-life friendship. Or, says Mahr, “If a dream is about a friend or lover dying, think about what aspect of you that person represents and how that aspect of you may be dying. That could be good or bad.”
Depending on how they appear in the dream, this determines the way you see them. In other words, those negative personality traits they have are “dying” in the waking world, as is your friendship with them.
What It Means If You Dream About A Child Dying
In general, the death of a child in your dream is about your own inner child and getting stuck in the struggles of daily life, meaning you aren’t spending time nurturing yourself.
If you dream about your own child dying, this also relates to your inner child, though it focuses more on trauma from the past, and moving on to live a better and brighter future.
Additionally, “Children are often potential, so a dream about a child dying may express a concern that a potential within you is dying,” adds Mahr.
What It Means If You Wake Up Before Dying In A Dream
Many times, people will have dreams about their own deaths; however, sometimes, they wake up right before they are about to die. Dream experts say that waking up before dying in a dream means our minds simply don’t know what lies beyond life, so we are unable to have that experience.
What It Means If You Dream About Dying From Suicide
Though suicide is a very serious subject, to dream about yourself dying from ending your life means there is some aspect of your life that you want to end. It could be a relationship, a career, or something else entirely.
What It Means If You Dream About A Boyfriend Dying
If you dream about your boyfriend dying, it means your relationship in the waking world is changing, both in the positive and negative sense. It could be that you two are simply drifting apart, that his behavior isn’t what it used to be, or that you will soon take the next step in your relationship.
What It Means If You Dream About A Girlfriend Dying
Similar to a boyfriend-involved death, dreaming of a girlfriend dying is your subconscious mind worrying about losing your partner. This dream also indicates that you may not want to be in the relationship anymore and wish to “free” yourself from its constraints.
What It Means If You Dream About A Stranger Dying
While many dreams about death involve people we know, sometimes we may dream of a complete stranger. This dream is a positive sign, however, and means that you will soon come into financial wealth. It can also indicate that you need to slow down and take your time making an important decision.
What It Means If You Dream About Dying In A Car Accident
If you dream about dying in a car crash or accident, this dream symbolizes the need to express your emotions. You may be holding them back for one reason or another, so consider it a sign to let it all out.
This dream can also mean that you must face your daily problems head-on, or that you need to approach life in a different way.
“Cars are usually symbols of the ego, of how we get around in the world. Car accident dreams are often a warning to be less reckless, to live more slowly and thoughtfully,” Mahr comments.
What It Means If You Dream About Dying From Drowning
Because dreams about water relate to emotions, dreaming about drowning means you’re suffering from emotional turmoil and are feeling overwhelmed as a result. This dream means you need to take the steps to overcome what you fear, and focus on renewal.
What It Means If You Dream About A Celebrity Dying
Dreaming about a celebrity dying indicates that they possess certain traits, and depending on what those traits are, it determines what they mean for you personally and how they relate to your life.
So, whether it’s their commitment to philanthropy, their talent, or even their negative attitude, it indicates that these specific qualities will soon come to an end in the real world.
A do-not-resuscitate order (DNR) is a legally binding order signed by a physician at a patient’s request. Its purpose is to let medical professionals know you do not want to be resuscitated if you suddenly go into cardiac arrest or stop breathing.
People who are chronically ill often regard a DNR as a graceful way to leave the world on their terms. The details of a DNR are usually discussed at the time of admission to a hospital, nursing facility, or hospice program.
This article explains what resuscitation means, its side effects, and its survival rates. It also describes the rules that often frame do not resuscitate orders, how to make a DNR order work for you, and some of the ethical issues worth considering.
What DNR Means
You may have seen TV shows set in hospitals in which a patient in cardiac arrest gets cardiopulmonary resuscitation (CPR), comes back to life, and is back to their old self in no time. In fact, being resuscitated is not so simple and can be dangerous in its own right.
Procedures used to resuscitate someone include:
Chest compressions: When a person’s heart stops beating, the heart cannot pump blood to the rest of the body, including the brain and lungs. Pushing down on the chest repeatedly can help keep blood flowing throughout the body until heart function is restored.
Intubation: When breathing becomes difficult or impossible due to an illness or injury, a patient may be intubated. This involves inserting an endotracheal tube through the mouth and into the airway. The tube is then connected to a ventilator, which pushes air into the lungs.
Cardioversion: Cardioversion is used to correct abnormal heart rhythms, including arrhythmias and atrial fibrillation (also known as AFib). This may be done using a set of paddles to deliver an electrical shock to the heart or via medication.
IV medications: Medications that are sometimes used in the case of cardiac arrest include epinephrine, amiodarone, vasopressin, and atropine sulfate. These are “crash cart medications,” so named because they can be found on the wheeled cart that medical professionals use during an emergency resuscitation.
For a patient in cardiac or respiratory arrest, a DNR states that none of these tactics will be used.1
Respiratory vs. Cardiac Arrest
The difference between respiratory and cardiac arrest is that respiratory arrest patients still have a beating heart that’s pushing blood around the body. Cardiac arrest patients do not. In both cases, though, a patient is unconscious and not breathing. Respiratory arrest will always lead to cardiac arrest if nothing is done to treat it.2
Resuscitation Side Effects
It’s important to realize that even if you are successfully resuscitated, you may end up with significant physical injuries as a result. For example, because the chest must be compressed hard and deep enough to pump the blood out of the heart, it can lead to broken ribs, punctured lungs, and possibly a damaged heart.3
Those who are resuscitated may also suffer brain damage. This can occur due to lack of blood flow to the brain followed by abnormal cell activity when blood flow to the brain is restored. Generally, the risk increases the longer the duration of CPR.4
Resuscitation Survival Rates
Survival statistics for resuscitation vary widely, partly due to the fact that there are many variables involved, including the age and health status of the patient and whether CPR was performed in a hospital, where emergency support is available.
A 2021 review looked at research published from 2008 onward that focused on the outcome of CPR in patients age 70 and older following in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA). Survival rates were 28.5% and 11.1%, respectively.5
Meanwhile, a Danish study found that 30-day survival rates among nursing home residents who received CPR after OHCA was only 7.7%6
Fatal Outcomes
It’s a painful irony that most people who suffer cardiac arrest are not in a hospital, nursing facility, or hospice program. About 70% of them are at home, and the vast majority (about 90%) die. CPR can double or triple a person’s chance of survival.7
Types of Orders
A DNR order is sometimes referred to by other names, though the directive not to resuscitate someone is the same. Two other names for these orders are:
No code: In a hospital, an order to withhold resuscitation is sometimes called a “no code” to distinguish it from a “full code” or “code blue,” both of which mean every effort should be made to resuscitate a patient.
Allow natural death (AND) orders: While a DNR order simply states that no attempts should be made to restart breathing or restart the heart if it stops, an AND order ensures that only comfort measures are taken.8 This would include withholding or discontinuing resuscitation, artificial feedings, fluids, and other measures that would prolong a natural death. These orders are typically used in hospice settings or elsewhere for terminally ill patients.
Discussion Matters
A study on DNRs and ANDs finds “healthcare providers should address the concept of natural death, provide comprehensive information, and help patients and families to overcome the barriers.”8
DNR Order Rules
The application of DNR orders varies from state to state, especially regarding out-of-hospital (meaning ambulance) care. Some states have standardized forms for DNR orders; if the order is not written on that specific form, it cannot be honored. Other states are less regimented and honor any type of clear DNR order.
Many states allow emergency responders to follow DNR orders written to other care providers, even if they aren’t written on standardized forms. For instance, in New York State, paramedics and emergency medical technicians are usually allowed to follow DNR orders written for the staff of a nursing home.
They also may be able to honor orders written for patients getting nursing care at home if the home care nurse has a copy of the DNR order in hand.1 Each state is different, and municipalities may differ within each state.
Regardless of the format or the venue, DNR orders almost always follow some of the same general rules; they have to in order to be valid. DNR orders must:
Be written by a doctor rather than verbalized.9 There are exceptions to this rule, such as an emergency medical service physician ordering an ambulance crew to withhold resuscitation via the radio or a registered nurse taking an order from an admitting doctor over the phone.1 Generally, there are safeguards for these exceptions to make sure the order is validated later.
Be signed by a doctor. In those cases where orders were taken by a nurse over the phone, states usually set a deadline for the doctor to physically verify and sign the order.
Include the patient’s name as well as the date. Depending on the state, orders may expire after a certain amount of time or there may be a deadline for the physician to follow up. Even if a DNR order doesn’t expire, a particularly old order may prompt a caregiver to revisit the decision.
Diligence on DNR Orders
A doctor writes a DNR order only after conferring with the patient (if this is possible), the patient’s appointed representative, or members of the patient’s family.
Making a DNR Order Work for You
If you opt for a DNR order, here’s what you can do to ensure your wishes are respected:
Keep the physical order on hand and display it wherever paramedics might find you. Make a point to tell them about the order when they arrive. It’s a good idea to have more than one copy available and displayed, as well as a copy to bring with you to the hospital.
If you are traveling, ask your traveling partners to keep a copy of your DNR order on them at all times.
Consider wearing a piece of medical jewelry to alert others of your intentions. MedicAlert Foundation provides jewelry designed specifically for patients with DNR orders. The foundation keeps a copy of the order on file and can fax it to anywhere in the world.
DNR Expresses Limits
A DNR order addresses the issue of CPR, but it does not include instructions for other treatments, such as pain medication or nutrition.10
Ethical Complications of DNR Orders
The inconsistent application of DNR orders means some patients may get less than optimal care once providers are aware of the presence of a DNR order.11 It’s important to remember that a DNR order is not an order to withhold all treatment. It’s an order not to resuscitate.
Even the mere mention of “DNR” can spawn a wide range of reactions, many of them emotionally charged. Discuss the options with your doctor and your family when everyone is calm and rational—and hopefully sooner rather than later.
Why a Patient Would Choose to Have a DNR Order
People with a terminal disease, such as advanced cancer or dementia, may not want CPR. A poor prognosis lowers the likelihood of survival, with a higher risk of heart, lung, and brain damage if resuscitation is attempted. Views on CPR within the medical community are ever-evolving too, with some professionals revisiting guidelines on how and why resuscitation should be considered.12
Summary
A do-not-resuscitate order instructs healthcare providers to refrain from cardiopulmonary resuscitation (CPR) if a patient’s breathing stops or if the patient’s heart stops beating. It can also pose a dilemma, but one worth considering, especially in the context of your health (or the health of a loved one).
Here’s why: CPR requires the heart to be compressed hard and deep enough to pump the blood out of the heart. As such, it can lead to broken ribs, punctured lungs, and possibly a damaged heart. Those who are resuscitated may also suffer brain damage.
These actions may be too much for someone in frail health. If you wish to explore a DNR order, it’s important to know that the orders vary from state to state. Be sure to investigate the rules in your state before proceeding.
A Word From Verywell
Understandably, loved ones often have difficulty talking about a DNR order and may feel they are “giving up” on their loved one. You can take charge of your end-of-life plans while you’re still able to do so, and investigate the rules governing DNR orders in your state. Keep in mind that even if you get a DNR order, you have the right to change your mind, revoke the order, and request CPR.10
Frequently Asked Questions
How do you get a do-not-resuscitate order?
You can get one from a hospital, nursing home, or hospice program. Most states have standard forms that you can download online.
Who can sign a do-not-resuscitate order?
A doctor must sign a DNR order with the consent of the patient or the patient’s healthcare proxy or designated power of attorney.9
Can a DNR be ignored?
The Patient Self Determination Act (PDSA) requires that the wishes of an individual and any existing advance directives be honored in the United States. However, providers do occasionally disregard a DNR due, for example, to lack of communication.13 It’s also possible that an existing DNR is honored but providers fail to confirm with a patient or their representative.14
