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Ashes to Ashes

Turning the dead into soil in Washington State.

By Tricia Romano

Micah Truman, founder of Return Home, uses the word beautiful many times during our conversation about his company’s unique burial process.

Terramation—what Return Home calls human composting—a two-month-long process that turns deceased bodies into soil, is new to the world. So new, in fact, that the service is offered in only a few places on the entire planet, and Washington State happens to be one.

Washington became the first place in the world to legalize human composting, thanks to a small, dedicated group of funeral directors led by Katrina Spade, a founder of the nonprofit Urban Death Project. As an undergrad at the University of Massachusetts Amherst, Spade had received the prestigious Echoing Green Fellowship and worked with scientists and biologists to develop a process that turns human remains into soil. In 2018, Spade pushed for human-composting legislation in Washington, later signed by Governor Jay Inslee in 2019. After it became law, she opened the world’s first human-composting center, Recompose, located in Seattle.

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Currently, there are only three states that provide this service: Washington, Colorado, and Oregon. Other states, including California, are working on similar legislation. In 2021, California Democratic assembly member Cristina Garcia, from Bell Gardens, introduced Assembly Bill 501, which would legalize “natural organic reduction.” It successfully passed out of the California State Assembly, the Senate Health Committee, and the Senate Business and Professions Committee, but it is currently tabled.

Return Home is located in Auburn, a suburb 20 miles south of Seattle. Speaking with me on a sunny spring morning, Truman recalls the story of a California family who recently used Return Home’s service.

The woman’s son had died suddenly, and she’d decided that because he hadn’t liked to fly when he was alive, she would transport him in a car herself. She drove from Northern California to Washington, her son’s body cooled and packed according to Return Home’s instructions. Once she arrived, Truman recalls, “She was able to sit with him and talk with him. We were able to place him in his vessel with his mom there.”

“It was one of the most beautiful things I’ve ever seen,” Truman says.

An entrepreneur and investor, Truman saw the Washington legislation as not just a business opportunity but an environmental one. The funeral industry isn’t particularly innovative: most people opt for either burial or cremation, and neither of those are good for the planet, he explains.

“Cremation has long been considered the environmental alternative. It’s the one that people use. It’s what I would have used, or my family, because we consider it the least environmentally impactful,” he says.

But, he points out, “Cremation uses about 30 gallons of fuel, spews about 540 pounds of CO2 into the air per cremation.”

The burial service Truman offers is different from a green burial, which, at its simplest, involves placing an unembalmed body directly into the ground without a box. Though green burial is also more natural than cremation, it presents the same problem that traditional cemeteries often face: limited space.

The idea of human composting might seem weird at first. Some “conservative religious groups” have reservations, says Truman, but he points out that the Catholic church was also once averse to cremation and is now on board. And if you think of human composting as slow burial, it’s less odd. Return Home uses a custom-made, heavily insulated plastic polycarbonate vessel; the body is placed inside with alfalfa, straw, and sawdust. After 30 days, the body disintegrates, leaving only bones, which are crushed and returned to the vessel to sit for another month. At the end of the cycle, 500 pounds of dense, nutrient-rich soil are created and can be used anywhere.

“We have to tell our families that it is extremely nutritionally dense,” Truman says. “So a lot of people would think, ‘OK, I will take a large pile of this and plant a tree in it,’ but there’s an enormous amount of nitrogen. It’s incredible. It’s the stuff of life.”

Joanna Ebenstein is the founder and creative director of Morbid Anatomy, an organization based out of New York City that has classes and lectures that encourage thinking differently about death and using creativity to explore the end of life. (Sample class: Make Your Own Memento Mori.) “We’re really about bringing death to the forefront,” says Ebenstein. A Bay Area native, she says that many people in the death-positive community are younger women and are more open to embracing natural burials, like human composting.

“A lot of them are focusing on trying to change attitudes about death so that we can live, so we can have better deaths. And that includes dying with more dignity, being able to choose when you die. And that also includes what you want done with your body and help people get to spend time with your body after you die,” Ebenstein says. “I certainly have seen many, many more people interested in this in the last 10 years than I ever have before.”

Though Return Home’s is the largest facility in the state—11,000 square feet, housing 70 vessels at a time, at full capacity—Truman is composting only 900 bodies a year.

With so few places offering the service in the country, Truman says 20 percent of his customers are from out of state: “Colorado, California, Missouri, Oregon. So we’ve had people come from all over there, and a number of them from California.”

Truman is still moved by the memory of the California family who came to Return Home.

At the end of the two-month process, the woman’s other sons made the drive up to gather the enriched soil made from their brother’s remains and brought him back to California.

“It was one of the most remarkable experiences I’ve ever had in my life,” Truman says.

You might even say it was beautiful.•

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What happens when a patient isn’t actively dying or recovering on their own?

Writing for the New York Times, Daniela Lamas, a pulmonary and critical-care physician at Brigham and Women’s Hospital, explains how doctors and loved ones “navigate death” in cases where “it becomes clear that the life that we can offer is not one that would be acceptable to the patient.”

Making the decision to ‘transition to comfort’

Many people believe that ICU doctors can easily determine whether a patient is going to die, but that’s not always true. “Our medicines and machines extend the lives of patients who would otherwise have died,” Lamas notes.

When a patient is fully relying on these measures—and it has become clear that they are not actively dying but are not improving either—doctors and family members must figure out how to “navigate death when it is not imminent and unavoidable but is instead a decision.”

During Lamas’ medical training, death unfolded in one of two ways: either in a moment of crisis, with doctors rushing into the room, trying to save a patient’s life, or in a quiet room, with loved ones gathered for the patient’s final breaths.

However, Lamas contends that there is a third form of death “when it becomes clear that the life that we can offer is not one that would be acceptable to the patient,” she writes. According to Lamas, this kind of death is planned for, occurring only after the medicines and machines keeping the patient alive are withdrawn.

“It is a strange thing to plan a death, but I have come to understand that this is part of our work in the I.C.U.,” Lamas adds.

For instance, Lamas recently cared for a cancer patient who had been intubated after experiencing a flare-up of underlying lung disease. Before the patient was put to sleep, she instructed her son to “Give her a chance to get better, but if that failed, she did not want a tracheostomy tube for a longer-term connection to the ventilator or months at a rehabilitation hospital,” Lamas recalls. “Her cancer was progressing, and that was not the way she wanted to spend the last year of her life.”

Lamas told the patient’s family that they would continue intensive interventions for two weeks, in “a time-limited trial of critical care.” According to Lamas, if the patient was not breathing on her own after two weeks, she would never be able to breath without a tracheostomy tube and extended rehabilitation—a best-case scenario the patient had already deemed unacceptable.

The day before the time-limited trial was supposed to end, the patient’s son and daughter told Lamas that they wanted to take her off the machines that evening if she was not going to improve.

“There is something uncomfortable about these conversations, where it feels as though we are asking family members to plan the end of a life,” Lamas writes. “It begins with a moment in the family meeting, when we have made the decision to ‘transition to comfort,’ and family members ask me what comes next.” However, “What they are asking, really, is how their loved one will die,” Lamas notes.

The ‘principle of double effect’

After loved ones have made the decision to “transition to comfort,” Lamas explains the next steps. “I tell them that when they are ready — as anyone really can be for any of this — we will stop the medications and the tubes that are prolonging life,” she writes.

In addition, Lamas explains that the bedside nurse will administer other medications to ensure that the patient does not experience pain. “Sometimes they ask if this medication will hasten death, and I explain that it can, but that our primary goal is always to relieve discomfort,” she adds.

Doctors refer to this balance as the “principle of double effect.” According to Lamas, doctors “accept the risk of a negative consequence like hastening death, so long as our intended outcome is to help the patient by alleviating symptoms.”

Ultimately, the pain-relieving drugs doctors administer during this process do not cause a patient’s death. Instead, they ensure that patients are as comfortable as possible while dying from their underlying disease.

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Walking in the Dark

— Creating a New Virtual Map in Your Brain After Loss

By

Mary-Frances O’Connor is a neuroscientist at the University of Arizona, where she researches the psychological and physiological costs of grief. In her recent book, The Grieving Brain, O’Connor uses insights from bereavement science to recast grieving as an immensely difficult learning problem. This adaptation from her book reveals how our loved ones are intricately incorporated into our brain’s mapping of the world, and what happens to our brain maps over time as we learn to live a meaningful life after a loved one is gone. — Antonia Violante, Books Editor

When I am explaining the neurobiology of grief, I usually start with a metaphor that is based on a familiar experience. However, for the metaphor to make sense, you have to accept a premise. The premise is that someone has stolen your dining room table.

Imagine waking up thirsty in the middle of the night. You get out of bed and head to the kitchen to get a glass of water. Down the hall, you cross the dark dining room toward the kitchen. At the moment that your hip should bump into the hard corner of the dining room table, you feel . . . hmm, what is it you feel? Nothing. You are suddenly aware that you don’t feel anything in that spot at the height of your hip. That is what you are aware of—not feeling something, something specific. The absence of something is what has drawn your attention. Which is weird—we usually think of something as drawing our attention—how can nothing draw our attention?

Well, in fact, you are not actually walking in this world. Or, more accurately, you are walking in two worlds most of the time. One world is a virtual reality map made up entirely in your head. Your brain is moving your human form through the virtual map it has created, which is why you can move through your house fairly easily in the dark; you are not using the external world to navigate. You are using your brain map to get around this familiar space, with your human body arriving where your brain has sent it.

You can think of this virtual brain map of the world as the Google map in your head. Have you ever had the experience of following voice directions, without fully paying attention to where you are driving? At some point, the voice tells you to turn onto a street, but you may discover that the street is actually a bike path. GPS and the world do not always match up. Like Google maps, your brain map relies on prior information it knows about the area. To keep you safe, however, the brain has entire areas devoted to error detection—perceiving any situations where the brain map and the real world do not match. It switches to incoming visual information when an error is detected (and, if it is nighttime, we may decide to flip on the lights). We rely on our brain maps because walking your body through your mental map of the world takes a lot less computing power than walking through your familiar house as though it were your first experience—as though you were discovering each time where the doorways and walls and furniture are, and deciding how to navigate each one.

No one expects their dining room table to get stolen. And no one expects their loved one to die. Even when a person has been ill for a very long time, no one knows what it will be like to walk through the world without this other person. My contribution as a scientist has been to study grief from the brain’s perspective, from the perspective that the brain is trying to solve a problem when faced with the absence of the most important person in our life. Grief is a heart-wrenchingly painful problem for the brain to solve, and grieving necessitates learning to live in the world with the absence of someone you love deeply, who is ingrained in your understanding of the world. This means that for the brain, your loved one is simultaneously gone and also everlasting, and you are walking through two worlds at the same time. You are navigating your life despite the fact that they have been stolen from you, a premise that makes no sense, and that is both confusing and upsetting.

For the brain, your loved one is simultaneously gone and also everlasting, and you are walking through two worlds at the same time.

In addition to carrying around wide-ranging virtual maps, another of the marvels of the brain is that it is a remarkably good prediction machine. Much of the cortex is configured to take in information and compare that information to what has happened before, to what it has learned through experience to expect. And because the brain excels at prediction, it often just fills in information that is not actually there—it completes the patterns it expects to see. 

When you walked through the space formerly occupied by the dining room table, your brain actually felt the table. Then it noticed the difference between the pattern of sensation that it expected and logged, and what actually happened. Imagine the man whose wife has returned home from work at six o’clock every day for years. After her death, when he hears a sound at six o’clock, his brain simply fills in the garage door opening. For that moment, his brain believed his wife was arriving home. And then the truth would bring a fresh wave of grief.

It requires additional time for you to consult with other parts of your brain that report your wife is no longer alive and could not possibly be opening the garage door. Sometimes all this occurs so quickly that it is below the threshold of consciousness, and all we know is that we are suddenly overwhelmed with tears. Therefore, perhaps it is not so surprising that we “see” and “feel” our loved ones after they have died, especially soon after the death. Our brain is filling them in by completing the incoming information from all around us, since they are the next association in a reliable chain of events. Seeing and feeling them is quite common, and it definitely isn’t evidence that something is wrong with us.

When we experience a loss through death, our brain initially cannot comprehend that the dimensions we usually use to locate our loved ones simply do not exist anymore.

Additionally, our predictions change slowly, because the brain knows better than to update its whole prediction plan based on a single event. Or even two events, or a dozen events. The brain computes the probabilities that something will happen. You have seen your loved one next to you in bed when you wake up every morning for days and weeks, months, and years. This is reliable lived experience. Abstract knowledge, like the knowledge that everyone will die someday, is not treated in the same way as lived experience. Our brain trusts and makes predictions based on our lived experience. When you wake up one morning and your loved one is not in the bed next to you, the idea that she has died is simply not true in terms of probability. For our brain, this is not true on day one, or day two, or for many days after her death. We need enough new lived experiences for our brain to develop new predictions, and that takes time.

The brain learns whether we intend to learn or not. It does not wait patiently until we say, “Hey, Siri,” and then begin encoding whatever happens next. Our brain continuously logs the information received through all of our senses, building up a vast store of probabilities and likelihoods, noting associations and parallels between events. Often this happens without our conscious awareness of those sensations, or of the associations made. This unintentional learning has pros and cons. Because learning is unrelated to our intentions, the brain is learning the real contingencies of the world, even when we are ignoring them or do not consciously notice them. Your brain continues to note the fact that your loved one is no longer present day after day and uses that information to update its predictions about whether they will be there tomorrow. That is why we say that time heals. But actually, it has less to do with time and more to do with experience. If you were in a coma for a month, you would not learn anything about how to function without your husband after you came out of the coma. But if you go about your daily life for a month, even without doing anything someone would recognize as “grieving,” you will have learned a great many things. You will learn that he didn’t come to breakfast thirty-one times. When you had a funny story to share, you called your best friend and not your husband. When you washed the laundry, you didn’t put any socks in his drawer.

If you go about your daily life for a month … you will have learned a great many things. You will learn that he didn’t come to breakfast thirty-one times. When you had a funny story to share, you called your best friend and not your husband.

When we experience a loss through death, our brain initially cannot comprehend that the dimensions we usually use to locate our loved ones simply do not exist anymore. We may even search for them, feeling like we might be a bit crazy for doing so. If we feel that we know where they are, even in an abstract place like Heaven, we may feel comforted that our virtual map just needs to be updated to include a place and time that we have never been. Updating also includes changing our prediction algorithm, learning the painful lessons of not filling in the gaps with the sights, sounds, and sensations of our loved ones.

Keep in mind that the brain cannot learn everything at once. You cannot go from arithmetic to calculus without many, many days of practicing multiplication tables and solving differential equations. In the same way, you cannot force yourself to learn overnight that your loved one is gone. However, you can allow your brain to have experiences, day after day, which will help to update that little gray computer. Taking in everything around us, which updates our virtual map and what our brain thinks will happen next, is a good start for being resilient in the face of great loss.

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How To Explain Death to a Child

It’s best to be honest and straightforward while remaining age-appropriate

When someone dies, it’s hard enough to deal with your own grief. But how on earth are you supposed to help your child through it, as well?

Pediatric psychologist Kate Eshleman, PsyD, talks about how to explain death to a child, including age-appropriate ways to discuss the concept of death and dying, and how to tell when your child needs a little bit of extra help from a mental health professional.

Why is explaining death to your child so hard?

There’s no getting around it: It’s emotionally grueling to tell your child that someone they knew or loved has died, and it’s not a task that any parent looks forward to. Plus, the difficulty is compounded by your own grief, as well as by your concerns about how to break the news, what your child will understand and whether you’ll be able to answer their questions.

“With death, often there’s either a long, drawn-out illness or a sudden, tragic event with no time for us to prepare,” Dr. Eshleman says. “When we’re struggling to cope, we anticipate that it will also be difficult to tell our children. We care about them, and we think they’re going to be upset, and we want to protect them from that.”

How to explain death to your child

Death is a part of life, so it’s important to help your child become accustomed to the idea that people (and pets) sometimes die.

“It’s something all around us and that kids will be exposed to,” Dr. Eshleman says, “but based on their age and development, kids will have varying understandings of what that means, including the permanency of it and associated factors, like whether it’s scary.”

Here’s the truth: Nothing will make it easy to talk to your child about death. But there are some guidelines you can follow that will help you explain what has happened in compassionate, understandable and age-appropriate ways. 

1. Be straightforward in your explanations

You may be inclined to soften the concept of death with euphemisms, but it’s best to be forthright and specific (while remaining age-appropriate).

If you just say that Grandpa is “gone,” for example, kids wonder: Where did he go? When is he coming home? Is it the same as when mom goes to work during the day? “That ambiguousness causes distress,” Dr. Eshleman notes, “so it’s important to use the actual words.”

The same is true of the lead-up to death. Let’s say Grandpa is terminally ill. Instead of just saying, “Grandpa is sick,” instead try, “Grandpa is sick with a kind of cancer. The medicine isn’t working anymore, and his body is tired of fighting. We think he will die soon.”

“You don’t want them to think that every time they or someone they love gets sick, they’re going to die,” Dr. Eshleman says, “so you want to be as specific with that labeling as you can.”

2. Honesty is the best policy

While you shouldn’t go into any gory or distressing details, always try to tell your child the facts while also using terms they can understand. “We always want to tell the truth in a developmentally appropriate way,” Dr. Eshleman says.

Remember that kids also hear information from the outside world, whether it’s online or from a classmate. The last thing you want is for your child to come home from school and tell you, “Johnny on the bus said that when you die, your body goes into the ground, but that’s not what you said!”

By telling your child the truth, even when it’s difficult or painful, you maintain their trust and your authority.

3. Ask and answer questions

Kids are naturally inquisitive and likely to have questions about death. Try to answer them using the guidelines above: honestly and in age-appropriate ways, using factual language and avoiding flowery euphemisms.

You can ask them questions, too. “It’s good to start conversations with open-ended questions,” Dr. Eshleman advises. “You can ask, ‘What do you think is going on with Grandpa?’ or ‘Where do you think Grandpa went?’”

Questions like “Is there anything on your mind?” and “Do you have any concerns?” help you ensure that your child understands what’s happening. It also gives you the chance to clear up any misunderstandings and address their worries.

And if your kid doesn’t want to talk, that’s also OK. “Don’t force them to engage in conversations they’re not ready or able to have, but do offer the opportunities,” Dr. Eshleman says.

4. Prepare them for upcoming rituals

Tell your kids what comes next so they know what to expect, You might say, for example, “We’re going to go to the funeral home. There are going to be a lot of people there. Many people might be crying, and lots of people that you don’t know are going to come and talk to you.”

You can also explain what they’ll see there (for example, flowers, a casket, the body of the deceased) and what people may be doing (for example, crying, hugging, talking, praying) to help them understand what’s to come.

5. Let kids make decisions

Telling kids what’s about to happen also allows them to choose how and whether to participate. Not sure what age is too young to attend a funeral? There’s no right or wrong answer. After you’ve told them what to expect, you can even let them decide for themselves.

“Again, we don’t want to force a child to do anything that they don’t want to do,” Dr. Eshleman emphasizes. “It’s about preparing them in advance and then following their lead.”

The same is true throughout every step of the process. If there’s an open casket, for example, they may not wish to see the body and may even want to stay in another room, or they may want to visit the casket and kiss Grandpa goodbye. Let your child decide for themselves.

6. Meld your faith with the facts

If your family is religious, incorporate your beliefs into the way you talk about death while also clearly and concretely explaining what’s happening.

“You may say, for example, ‘We’re going to go to Grandpa’s funeral, and then they’ll put his body in the ground, which is where it will stay — but his spirit is in heaven,’ or whatever is consistent with your family’s beliefs,” Dr. Eshleman suggests.

7. Try not to project your emotions onto your kids

Have you ever been to a funeral home where adults are crying and hugging while little kids laugh and play nearby? It can feel jarring, but it’s actually an understandable response for children to have.

In the simplest of terms, adults have more life experience than kids do, which means we can’t expect little ones to know or understand everything we do — including social cues and emotional responses.

“As adults, we have certain thoughts, feelings and associations that we often project onto kids,” Dr. Eshleman explains. “Even when everyone else is grieving, kids may not feel the same way. It’s not always a time of sadness for them.”

8. Let them feel their feelings

Speaking of sadness, though, here’s an important reminder: “When something sad happens, it’s appropriate to feel sad,” Dr. Eshleman reiterates. For kids, that can manifest in behaviors like:

It’s important to keep an eye on your kids to make sure these responses don’t continue indefinitely. But don’t put the kibosh on them right away. In the aftermath of a loss, it’s natural for kids to express their sadness.

It can be helpful for kids to see you feeling your feelings, too. It’s OK — and even healthy — to let children witness your emotional responses. Saying, for example, “I’m crying because I’m feeling sad. I loved Grandpa very much, and I’m sad that he’s gone,” shows kids that it’s normal to feel and express a range of emotions.

9. Make them feel safe

When someone dies under tragic or violent circumstances, it can be even harder to make sense of what to tell kids. And there’s the added layer of wanting to ensure that they feel protected from harm.

“The truth is, there are a lot of things we can’t control, from mass shootings to the pandemic, and we can’t always keep our kids safe,” Dr. Eshleman notes, “but it’s important to discuss the ways they are safe and the ways that we continue to try to keep them safe.”

10. Keep talking about their loved one

Talking about the person who died can help both you and your child cope with grief, whether through telling stories, looking at pictures or just continuing to mention them in small ways.

“Let’s say you’re at the grocery store, and you pick up a box of cereal,” Dr. Eshleman posits. “You can say, ‘Oh, this was Grandpa’s favorite kind,’ or, ‘Remember the last time you had your friend over and you had this for breakfast?’”

“Sometimes, people are afraid of bringing up people who have died because they don’t want to make others sad,” she continues, “but it’s OK to feel sad. Continue to talk about loved ones who have died instead of avoiding it.”

11. Ask for help and consider mental health resources

You don’t have to cope alone, and you don’t have to help your kid cope alone, either. If you’re having trouble figuring out what to say or how to deal, ask others for help.

“Never be afraid to run it by your child’s pediatrician or your own primary care doctor or even your friends, just to get their input and feedback,” Dr. Eshleman says.

And if your child seems to be having an especially difficult time after a loss, those same medical professionals can weigh in on how to get them the extra support they need.

At what age should you explain death to your child?

There’s no age too young to tell your child that someone they knew or loved has died. Again, honesty is the best policy. But Dr. Eshleman reiterates how important it is to speak to your kids on their level, in terms they can comprehend.

“It’s very important to meet each child where they are, developmentally,” she says. “Ask the child what they know and what they understand, then follow their lead.”

Ultimately, she adds, kids are incredibly resilient. “If we do our best to support them before, during and after a loss, it’s likely that they are going to come out of it OK.”

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Is Alexa’s voice of the dead a healthy way to grieve a loved one?

By Riya Anne Polcastro

Amazon’s Alexa is getting an update that may soothe some grieving souls while making others’ skin crawl. The AI enhancement will enable the device to replicate a deceased loved one’s voice from less than a minute of recording, allowing users the opportunity to connect with memories in a much more extensive manner than simply listening to old voicemail messages or recordings might provide.

Still, there are reasonable concerns regarding how this technology could impact unprocessed emotions or even be used for unscrupulous purposes.

The ‘why’ behind the new AI

Rohit Prasad, senior vice president and head scientist for Alexa, told attendees at this year’s Amazon re:MARS conference  that while AI cannot take away the grief that comes from losing a loved one, it can help keep the memories around by providing a connection with their voice. A video played at the conference featured a child asking Alexa to have his grandmother – who had already died – read a book. The device obliged and read from “The Wonderful Wizard of Oz” in the grandmother’s voice. It was able to do so by analyzing a short clip of her voice and creating an AI version of it.

At the conference, Prasad mentioned “the companionship relationship” people have with their Alexa devices:

“Human attributes like empathy and affect are key to building trust,” he said. “These attributes have become even more important in these times of the ongoing pandemic, when so many of us have lost someone we love.” By giving the voice those same attributes, his plan is for the voice to be able to connect with people in a way that helps maintain their memories long after their loved one is gone.

What does the research say?

While it’s yet to be proven whether an AI facsimile of a loved one’s voice has the potential to assist in the grieving process, there’s hope there could be a real benefit to the application. Research into how hearing a mother’s voice can ease stress among schoolchildren suggests the potential is there.

Leslie Seltzer, a biological anthropologist at the University of Wisconsin–Madison, determined that talking to Mom on the phone can have the same calming effects as receiving in-person comfort—which included hugs. In a follow-up study that demonstrated the same effects don’t hold for students conversing with their mothers through instant messages, the researcher explained that speaking with someone trustworthy has the power to reduce cortisol and increase oxytocin.

There is, however, a fundamental difference between talking to a living relative on the phone and interacting with an AI imitation of someone who is gone. Anecdotal evidence of friends and family listening to old recordings of their loved ones suggests that what is healing for some may be devastating for others. While some people report that listening to old voicemails, for example, help them reconnect and process their grief, others have said it made the pain worse.

What about the experts?

Dianne Gray, a certified grief specialist, also pointed out it could go either way. She explained the Alexa feature could “be immensely helpful or, conversely, act as a trigger that brings grief back up to the surface.”

She suggested regardless of the situation, the mourner should be in a safe space that will allow them enough time and support to work through any unexpected emotions that come up.

Likewise, Holly Zell, a licensed clinical professional counselor intern specializing in death and grief, agreed:

“Every person’s grief experience is unique, and each grief experience a person has across their life is unique,” she said. “What might be helpful in one situation might feel distressing or harmful in another.”

Zell is concerned the AI could interfere with the grieving process, particularly with the example given at the conference of a child listening to their grandmother read a story.

“One of the most challenging and also important aspects of grief is acceptance, which involves acknowledging that the death has happened and that certain things change in relationships after death,” she said. “It can be healthy to have a sense of a ‘continued’ relationship after death, but this is not meant to be in conflict with acceptance.”

Zell instead encourages having loved ones record messages before they pass. Those messages can also provide that connection that can be so crucial, Gray explained.

“This connection via sound can continue long after the loved one has died,” she said. “A common fear of the bereaved is that they will forget what a loved one’s voice sounded like.”

She’s hopeful that by hearing the voice of the deceased without their physical body, the feature can help people navigate acceptance.

“Research will be interesting on this topic.”

Additionally, Gray sees potential benefit for seniors with low vision who may find it easier to use the 100% voice-activated device than if they were trying to pull up recordings on their phones.

That doesn’t mean the AI is risk-free, she explained.

“What if there are things left unsaid, disharmony or abuse between the voice on the Alexa device and the beloved? What if the message on the Alexa device is not as kind, gentle or loving as it should or could be?”

Gray pointed to the unfortunate reality that people often die with close relationships still in tatters—and that their voice could have a negative impact on survivors.

Zell said she also remains unconvinced at this point.

“I’m sure there are people who will find this comforting or helpful. I personally and professionally feel skeptical of this as a useful tool, and would strongly encourage people to find their own meaningful ways to include their lost loved ones into their lives through photos, stories, videos/recordings and other experiences.”

Complete Article ↪HERE↩!

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In the I.C.U., Dying Sometimes Feels Like a Choice

By By Daniela J. Lamas

My patient’s wife had just one question: Was her husband dying?

She knew that he was still on the ventilator even after all these weeks, his lungs too sick and his body too weak to breathe on his own. That he still needed a continuous dialysis machine to do the work of his kidneys. That he had yet to wake up in any meaningful way, though his brain scans showed nothing amiss. That it had been more than 50 days since he entered the hospital and we needed to talk about what would come next.

But when she stood there at the bedside, her husband looked much the same to her as he had a week ago, much the same as he might look next week if we continued to push forward. And she had to ask: Why did we need to have this conversation today? Was her husband dying?

You might think this is an easy question to answer. And yet here in the intensive care unit, it is not. Our medicines and machines extend the lives of patients who would otherwise have died. But what happens when it becomes clear that a patient is not actively dying, but not getting better either? How do doctors and family members navigate death when it is not imminent and unavoidable, but is instead a decision?

During my medical training, death happened in one of two ways. It was either a moment of crisis, doctors rushing into a room, all sound and fury and chest compressions for minutes that felt like hours. Or it was something quieter, entirely divorced from machines, family gathered for the last breaths when the lungs were failing, or the cancer had spread too far.

But there’s a third form that dying takes, when it becomes clear that the life that we can offer is not one that would be acceptable to the patient. It is a death that is made imminent only by the withdrawal of medicines and machines — a death that we plan for. It is a strange thing to plan a death, but I have come to understand that this is part of our work in the I.C.U.

A few months ago, I took care of a cancer patient in her 70s who had been intubated because of a flare-up of an underlying lung disease. In the moments before the anesthesiologists put her to sleep and placed the breathing tube down her throat, she had given her son instructions: Give her a chance to get better, but if that failed, she did not want a tracheostomy tube for a longer-term connection to the ventilator or months at a rehabilitation hospital. Her cancer was progressing, and that was not the way she wanted to spend the last year of her life.

I told her family that we would continue our intensive interventions for two weeks, a “time-limited trial of critical care,” as we often call it. If my patient was not breathing on her own at that point, then she never would never be — not without a trach and protracted rehab, a best-case scenario that she would find unacceptable. A week passed. She improved a bit and her family let themselves hope, only to be devastated days later when she worsened again.

Then, the day before the time-limited trial was to end, my patient’s son and daughter took me aside. They could not bring themselves to leave that night and return the next morning to hear the words that now seemed inevitable. If their mother was not going to improve, they wanted to take her off the machines that evening. The next day was her grandson’s birthday. She would not have wanted the little boy’s celebration to be forever intertwined with the sadness of her death. Perhaps they could wait until the day after the birthday, but that might only prolong their mother’s suffering.

There is something uncomfortable about these conversations, where it feels as though we are asking family members to plan the end of a life. It begins with a moment in the family meeting, when we have made the decision to “transition to comfort,” and family members ask me what comes next. What they are asking, really, is how their loved one will die.

As gently as I can, I tell them that when they are ready — as anyone really can be for any of this — we will stop the medications and the tubes that are prolonging life. I tell them that the bedside nurse will give other meds, often morphine or a similar drug, to make sure that their loved one is not in pain. Sometimes they ask if this medication will hasten death, and I explain that it can, but that our primary goal is always to relieve discomfort.

We even have a term for this balance, the “principle of double effect” — as doctors, we accept the risk of a negative consequence like hastening death, so long as our intended outcome is to help the patient by alleviating symptoms. The pain-relieving meds that we administer do not themselves cause death; instead they ensure that our patients are as comfortable as they can be while dying from their underlying disease.

Some family members ask us to stop everything all at once. Others ask for a longer process, to stop one medicine and then another. Someone recently asked the nurse to let every medication run out and not to replace the IV bags. Some ask us to remove the breathing tube, others do not. I am often surprised to what extent people have ideas about what feels right to them, about how the unimaginable should play out. Sometimes there is music. Jerry Garcia. Beethoven. For others, this is all one decision too many, and they sit in silence.

A resident doctor in training came to me recently after one such family meeting, worried that by telling a family that their loved one was dying, he had made it true. If we define dying solely by physiology, by a falling blood pressure or oxygen level, then perhaps that concern is valid. But if we broaden our definition, if we think of dying in the intensive care unit as something that begins when an acceptable outcome is no longer possible, then we are acknowledging the inevitable.

Which is what I told my patient’s wife that day outside his room. We had given her husband every chance to rebound, to show us that he could make it through, but the insults his body faced were too great. We could press on, but to what end? He would never make it home, never be able to do the things that made his life worth living.

She was right, the timing of this conversation was, in a way, arbitrary. Had I been dealing with a patient in extremis, I might not have stopped her outside the room that day. But once we recognized the reality of her husband’s medical condition, what choice was there?

That night, my patient’s wife made the decision to take him off the ventilator. The nurses titrated the pain medications that ran through his veins as she held vigil at his bedside. And after weeks of critical care limbo, the answer to her question was finally clear. Her husband was dying.

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After death, you’re aware that you’ve died, say scientists

Your subjective experience might not end the moment your heart stops, research on near-death experiences suggests.

By Philip Perry

Time of death is considered when a person has gone into cardiac arrest, which is the cessation of the electrical impulse that drives the heartbeat. As a result, the heart locks up. This moment when the heart stops is considered by medical professionals to be the clearest indication that someone has died.

But what happens inside our mind during this process? Does death immediately overtake our subjective experience or does it slowly creep in?

Scientists have studied near-death experiences (NDEs) in an attempt to gain insights into how death overcomes the brain. What they’ve found is remarkable: A surge of electricity enters the brain moments before brain death. One 2013 study, which examined electrical signals inside the heads of rats, found that the rodents entered a hyper-alert state just before death.

Some scientists are beginning to think that NDEs are caused by reduced blood flow, coupled with abnormal electrical behavior inside the brain. So, the stereotypical tunnel of white light might derive from a surge in neural activity. Dr. Sam Parnia is the director of critical care and resuscitation research, at NYU Langone School of Medicine, in New York City. He and colleagues have investigated exactly how the brain dies.

Our cerebral cortex is likely active 2–20 seconds after cardiac arrest.

In previous work, Dr. Parnia has conducted animal studies looking at the moments before and after death. He’s also investigated near-death experiences. “Many times, those who have had such experiences talk about floating around the room and being aware of the medical team working on their body,” Dr. Parnia told Live Science. “They’ll describe watching doctors and nurses working and they’ll describe having awareness of full conversations, of visual things that were going on, that would otherwise not be known to them.”

Medical staff confirm this, he said. But how could people who were technically dead be cognizant of what’s happening around them? Even after our breathing and heartbeat stop, we remain conscious for about two to 20 seconds, Dr. Parnia says. That’s how long the cerebral cortex is thought to last without oxygen. This is the thinking and decision-making part of the brain. It’s also responsible for deciphering the information gathered from our senses.

According to Dr. Parnia, during this period, “You lose all your brain stem reflexes — your gag reflex, your pupil reflex, all that is gone.” Brain waves from the cerebral cortex soon become undetectable. Even so, it can take hours for our thinking organ to fully shut down.

Usually, when the heart stops beating, someone performs CPR (cardiopulmonary resuscitation). This will provide about 15% of the oxygen needed to perform normal brain function. “If you manage to restart the heart, which is what CPR attempts to do, you’ll gradually start to get the brain functioning again,” Dr. Parnia said. “The longer you’re doing CPR, those brain cell death pathways are still happening — they’re just happening at a slightly slower rate.”

Other research from Dr. Parnia and his colleagues examined the large numbers of Europeans and Americans who have experienced cardiac arrest and survived. “In the same way that a group of researchers might be studying the qualitative nature of the human experience of ‘love,’” he said, “we’re trying to understand the exact features that people experience when they go through death, because we understand that this is going to reflect the universal experience we’re all going to have when we die.”

One of the objectives is to observe how the brain acts and reacts during cardiac arrest, throughout both the processes of death and revival. How much oxygen exactly does it take to reboot the brain? How is the brain affected after revival? Learning where the lines are drawn might improve resuscitation techniques, which could save countless lives per year.

“At the same time, we also study the human mind and consciousness in the context of death,” Dr. Parnia said, “to understand whether consciousness becomes annihilated or whether it continues after you’ve died for some period of time — and how that relates to what’s happening inside the brain in real time.”

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