Tag: Death And Dying

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What Jewish law says about suicide and assisted dying


Jewish law recognises patient choice as decisive in some situations where assisted dying may be an option.

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[I]n November, Victoria became the first Australian state to legalise voluntary assisted dying. From mid-2019, competent, terminally ill adults who are stricken with an incurable and progressive physical or mental disease and unable to gain relief from their suffering will be able to access a substance that will let them end their lives.

The law reflects the contemporary secular approach to biomedical law and ethics, in which individual autonomy trumps the principle of the value of human life.

In line with this approach, competent terminally ill adults who find themselves trapped by disease from which they feel that their only deliverance is death may choose to end their lives in accordance with the law.

By contrast, Jewish law (halakhah) is obligation-based, and the preservation of human life is a cardinal commandment. Both suicide and self-endangerment are forbidden (Genesis 9:5; Deuteronomy 4:15). Maimonides explains that our bodies are Divine property and any deliberate attempt to destroy them is prohibited.

A similar view is attributed to Socrates in the Phaedo. He states that, in general, suicide is forbidden since it infringes on the property rights of the gods.

‘Soft autonomy’ and assisted dying

Jewish law recognises patient choice as decisive in some situations. This is not so much a value as a solution to a particularly difficult case involving a clash between two competing values.

Famed Jewish law scholar and rabbi Moshe Feinstein used this type of “soft autonomy” in a case in which a patient wanted to risk an assured but low-quality short-term lifespan for the possibility of gaining long-term life expectancy.

In permitting the patient to choose the highly risky operation, Rabbi Feinstein held that if rational people in general would be prepared to choose the operation, it would constitute a legitimate option – and ownership of the body would be transferred to the patient.

In another decision, he ruled that a competent, terminally ill adult ought not to be pressured into accepting artificial nutrition, even though failure to do so would precipitate his death. Here, Rabbi Feinstein took the terminal patient’s wishes into account. He laid down the principle of non-traumatisation of the terminally ill.

‘Soft autonomy’ and suicide

This soft autonomy model is also applicable to suicide.

In general, suicide is forbidden under Jewish law. Sanctions include non-observance of mourning rites and separate burial. However, there are situations in which a person may choose to take their own life because of a conflict between legitimate halakhic values.

The biblical account of King Saul’s suicide is interpreted to mean that one may take their own life to prevent the desecration of the Divine name by having a king of Israel fall into enemy hands.

Another view is that suicide may be committed to avoid physical or mental suffering. With regard to the permissibility of suicide during the Holocaust, Rabbi Ephraim Oschry permitted suicide to avoid the agony of witnessing the destruction of one’s family and community – but added that the decision should not be publicised.

The lesson to be learned from this is that any relaxation of the prohibition on suicide in cases of extreme suffering should be accompanied by a public education program. This program would be designed to both strengthen the value of life and deepen society’s understanding of its fundamentally sacred nature.

Complete Article ↪HERE↩!

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‘It’s all about making this better’

In the season of giving, hospice grants patients’ end-of-life wishes

From left, Deborah Holmes, Leslie White and Lisa Price work with patients of all ages at Seasons Hospice. Their job is to provide comfort and love to a person in his or her last days, weeks and even months.

By Isabel Hughes

[D]eborah Holmes adjusted her glasses, eyes watering as she glanced up at the ceiling of Seasons Hospice’s family room.

“I’m glad I didn’t wear mascara again today, though none of us [nurses] do much because we cry so often,” she said, smiling as her voice cracked. “I’ve almost given up wearing glasses they fog up so much too.”

Steadying her voice, Holmes laughed — a mixture of sadness, humor and joy.

Though the holiday season is often thought of as an especially important time for giving and making wishes come true, for Holmes and her fellow employees at Seasons Hospice, every day is an important time to grant wishes to their patients, the overwhelming majority of who are dying.

Unlike hospitals, which mainly focus on curative measures for patients — even those who are terminally ill — hospices are intended to provide comfort and love to a person in his or her last days, weeks and even months.

Hospice workers give the gift of dignified end-of-life care daily, holiday season or not, Holmes said, which she added is the most rewarding part of her job.

“Seeing those patients be free of those acute symptoms — to not be writhing in pain, to have that hospice success, to see them share laughs and hugs and things with their grandchildren and their own children — that’s the best,” she said.

“At night when I lay down — and it’s me and God, that’s who I deal with — knowing that that family member made it for their son to come home from the military, for that nephew to come in from out-of-state, for that patient to have their cat on their lap or for them to eat lunch without their oxygen because that’s what they want to do and they don’t care how low their stats drop, it’s those things, just making sure they have what they need, that’s my measure of success.”

The success varies from patient to patient, though, who range in age anywhere from 18 to 98.

“We do get very young patients; usually 18 years old and up, though we do get a lot of 30s, a lot of early 40s and 50s [and] a lot of 60s,” Holmes said. “Usually, cancer is the culprit, unfortunately, and those are especially hard because the [patients] generally have young families and their parents are still with us a lot of times. To have that parent experience the loss of their child at such an early age is absolutely devastating.”

As she continues, Holmes’ smile fades, sadness beginning to cloud her coffee-colored eyes.

“I’ll be honest,” she said. “In my 25 years of nursing, fortunately and unfortunately I’ve been involved in quite a number of situations where you do kind of go numb after a while. When I meet these family members, too, they don’t know what hospice is and I think it’s because there’s not a lot of talk in the community about hospice.

She added: “We’re not here to take anybody’s lives; we’re here to enhance the time that is left, so I do comedy with them. I may crack a little joke and I kind of develop a little joke with each and every family member or patient and that’s what I keep thinking about. It just brings a smile to my face because you know that was a connection that you made with those people.”

It’s the connections, too, that hospice employees make with one another that lighten the nurses’ daily burdens, as well as family, friends and pets.

In Bulldog country, the University of Georgia’s recent SEC championship and the team’s January trip to Pasadena, Calif., where they’ll challenge No. 2 seed Oklahoma in the Rose Bowl Game, also helps, Holmes said.

Lisa Price, one of the facility’s social workers, smiled, half-whispering ‘Go Dawgs’ as Holmes paused, mid-sentence.

“That’s the thing about it,” Price interjected. “We’re a big team and none of us could do our job without the others and the families, too. We have a good social and psych support here, and we’re a team.”

That team is part of what keeps Holmes coming back to work every morning, good days and bad. Her patients, too, make the job worth it.

And, at the end of the day, Holmes said she also knows she can turn on her radio, cued to a Pandora comedy station, and just laugh.

“I have a really good sense of humor; I love to laugh and I love to crack jokes,” she said. “I think it’s real important to keep a good sense of humor because even patients who are terminal, they still like to laugh and joke and kid, and we really enjoy that part, too. It’s not all crying; it can be, some situations that’s just where you’re at, but it’s all about making this better.”

Complete Article ↪HERE↩!

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When Grief Becomes a Mental Health Issue

By Becky Oberg

[W]hat do you do when grief becomes a mental health issue? Recently I lost a friend to suicide, and it made me think of all the other losses I’ve suffered. Two memories stand out in my mind–the death of my maternal grandfather to cancer and the death of my paternal grandmother to a stroke. One was a mental health issue, the other was not. There are several things people can do when grief becomes a mental health issue.

Grief and A Tale of Two Deaths

My maternal grandfather got cancer in the ’80s, when it was a virtual death sentence. My family never discussed it. It was especially hard on my mother, who took the stress out on the children. To this day, she does not like Halloween (when he was diagnosed), Thanksgiving (the last holiday he spent with the family; he told us to go and eat the turkey instead of worrying about him and we children said our final goodbyes), and Christmas Eve (when he died). Things at home fell apart, and I became well acquainted with depression–to the point where a teacher said something. It took me years to even talk about it–it led to emotional abuse at home, where it was understood we would “get over it.”

The death of my paternal grandmother was shortly after I graduated college. The family supported each other, and it didn’t hurt as badly even though it was sudden. My boss gave me time off and sent flowers, and the town brought enough food to feed all 13 of us immediate family members several times over (as my cousin said, “We’re Germans. We eat.”) I left shortly after the funeral because I had a psychiatrist’s appointment the next day. She said to me, “You look depressed. I’m increasing your medication.”

I replied, “I just buried my grandma. I’m supposed to look depressed. If you’re going to increase my medication for normal reactions to life events, this is just legal substance abuse.”

It did not go over well, but I still stand by my statement. Sometimes grief becomes a mental health issue, but, sometimes, it doesn’t. It depends on a number of factors.

Factors in Grieving Becoming a Mental Health Issue

Obviously, the relationship you had with the person will impact your grieving. But so will several other things, like the way he or she died, religious beliefs, and support from other family members and friends. Having lost friends to suicide, murder, disease, accidents, and natural causes, I can honestly say traumatic death is harder on the survivors and almost always requires mental health counseling. But it seems to be random when it comes to non-traumatic death.

Faith is a double-edged sword. It can help the loved ones to know the deceased is no longer suffering. However, as is especially true in the case of traumatic grief, faith can be sorely wanting. Questioning “why” can be frowned on in some circles, but sometimes we need to question “why.” In addition, religion frowns on suicide–mourners at my friend’s funeral remarked that it was good we could talk about it since they wouldn’t be able to at most churches.

Support is crucial. I remember when a psychologist made an offhand remark to me about “the first year” of grieving. Seeing my puzzlement and concerned about my comment, “Aren’t we supposed to be over it by then?”, he explained that grief is a process that doesn’t have a time limit or set order (Nine Common Myths And Realities About Grief). He also explained to me it was okay to talk about it–and I joined his grief support group to do just that.

How to Tell When Grief Requires Mental Health Help

I needed help after my maternal grandfather died, largely because my mother needed but did not get help after his death. As she cycled through denial, anger–a lot of anger–and depression; it seemed she would never accept it. She became emotionally abusive toward us kids, but maintained some semblance of a normal life for years. No one knew the hell that was going on at home. Eventually she came to terms with it, but not before some lasting damage was done to us kids.

If you can’t talk about your grieving, you need mental health help. If you take your grief out on others, you need mental health help. And if you want to join your deceased loved one sooner rather than later, run, don’t walk, to a counselor (Suicide Prevention Chat: How Does It Work?).

Remembering the loved one will bring happiness and pain, sometimes within hours of each other–as my then-six-year-old brother observed after my maternal grandfather’s funeral, “People go to the church and cry then come back to the house and have a party.”

It is normal to reflect on the life of one who died, the circumstances leading up to the death, the death itself, and the funeral with mixed emotions. Obsessing, however, is not, and neither is constant sadness. Seek mental health help if grief begins to interfere with your ability to live your life.

You deserve to come to terms with the death of your loved one, and chances are that’s what your loved one would want. Don’t hesitate to ask for mental health help if you need it.

Complete Article ↪HERE↩!

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The Long Goodbye

Coping With Sadness And Grief Before A Loved One Dies

By Judith Graham

[F]or years before her death at age 96, Nancy Lundebjerg’s mother underwent a long, slow decline.

Arthritis made it hard for Margaret Lundebjerg to get around. After two hip surgeries, she needed a walker when she was out and about.

Incontinence was a source of discomfort, as was the need to rely on aides to help her perform daily chores.

Little by little, Margaret became frail and isolated. “There was a sadness to seeing my mother’s circle of life become diminished,” said Nancy Lundebjerg, 58, CEO of the American Geriatrics Society, who wrote about her experiences in the organization’s journal.

The anguish accompanying aging isn’t openly discussed very often, nor is its companion: grief. Instead, these emotions are typically acknowledged only after a loved one’s death, when formal rituals recognizing a person’s passing —the wake, the funeral, the shiva — begin.

But frailty and serious illness can involve significant losses over an extended period of time, giving rise to sadness and grief for years.

The loss of independence may be marked by the need to use a walker or a wheelchair. The loss of a cherished role may dishearten an older woman who is no longer able to cook dinner for her extended family, gathered at the holidays. The loss of shared memories may be painful for adult children when their older father is diagnosed with dementia. And these are but a few examples.

Looming over everything is the loss of the future that an older adult and his or her family imagined they might have, often accompanied by anxiety and dread.

This pileup of complex emotions is known as “anticipatory loss.” “The deterioration of function, disability and suffering have their own grieving processes, but helping families deal with that isn’t built into the health care system,” said Dr. John Rolland, professor of psychiatry at Northwestern University’s Feinberg School of Medicine and author of “Families, Illness and Disability: An Integrative Treatment Model.”

Rolland and several other experts offered advice on how to deal with difficult emotions that can arise with frailty or serious illness:

Acknowledge Your Feelings

“Grief starts the moment someone with a serious illness receives the diagnosis,” said Tammy Brannen-Smith, director of grief and loss services at Pathways, a hospice in Fort Collins, Colo. But it doesn’t stop there. Each time a capacity is lost — for instance, an older adult’s ability to negotiate stairs, to drive or to manage household finances — sadness and grief can arise afresh. Brannen-Smith encourages people to acknowledge their feelings and try to “normalize them, because people don’t understand that everyone goes through this.”

Talk Openly

When families avoid talking about an aging parent’s frailty or serious illness, the person with the condition can become isolated and family relationships can become strained.

“My view is, you’re better off trying to get through whatever you’re facing together,” Rolland said.

When Rolland works with couples who are dealing with multiple sclerosis, for instance, he asks them to make a list of things they’d like to discuss but don’t. “Usually, there’s about a 75 percent overlap, and it’s a tremendous relief to most people to find out they don’t have to keep things locked up inside,” he said.

“People who are facing serious illness think about what might lie ahead all the time,” Rolland said. “For a family member not to bring this up, for everyone to be off in their own grieving pockets, alone, isn’t helpful.”

Communicate Sensitively

Abigail Levinson Marks, a clinical psychologist in San Francisco, regularly works with adults who have brain tumors, which can alter their thinking and wipe out their memories, as dementia does for millions of older adults.

“People with these conditions aren’t the same as they were before, but it would be heartbreaking for them to know that you didn’t see them as the same person,” she said. “So, the truth becomes something that cannot be named and that everybody avoids, for fear of shaming the person.”

In her practice, Marks asks “people to share what each person is going through and not worry about protecting each other from what they’re feeling,” she explained. “Because protecting each other leads to feeling more alone and magnifies the feelings of loss.”

For a caregiver of someone with dementia, that might mean saying,“Sometimes you might see a look crossing my face and think that I’m disappointed. It’s not that I’m upset with you. It’s that I’m sad that there are things that happened in our past that we don’t remember together.”

For someone who has suffered a stroke, it might mean encouraging them to open up about how hard it is to lose a measure of independence and be seen as someone who’s disabled.

Lean In

How people respond to sadness and grief varies, depending on their personality, past experiences, the relationship they have with the person who’s frail or ill, and the nature of that person’s condition.

“Sadness can make you cherish a person even more and appreciate small moments of connection,” said Barry Jacobs, a Pennsylvania psychologist and co-author of “AARP Meditations for Caregivers.”

Some people, however, can’t tolerate feeling this distress and end up distancing themselves from someone whose health is declining. Others might show up in person but focus on tasks instead of allowing themselves to connect emotionally.

If possible, lean in rather than letting yourself become distant. “Cherish the time that you have together,” Jacobs said. “Rather than pulling back, move toward the person and be as engaged with them as possible, particularly on an emotional level.” In the end, connection eases the pain of grief, and you’ll be glad you had this time with the person.

Seek Support

“Don’t confront grief alone or in isolation,” said Alan Wolfelt, founder and director of the Center for Loss & Life Transition in Fort Collins, Colo. “Have people around you who are supportive and who will be present for you” — family members, friends, people from a support group, whoever is willing to be a companion through your journey through serious illness.

Ultimately, this journey will help shape how you ultimately experience a loved one’s death.

Wolfelt describes mourning his mother twice. “The day she was diagnosed with Alzheimer’s and all the days I watched her dwindle. And then, the day she died, I had to begin mourning again, at a whole other level.”

But Lundebjerg of the American Geriatrics Society found a measure of peace when her mother finally passed away, after two seizures and the family’s decision not to pursue further treatment. “It was OK that she died because she was ready — she had made that very clear. And I had come to peace, over a very long time, with the fact that this was going to be coming.”

Complete Article ↪HERE↩!

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Researchers find racial disparities in intensity of care at the end of life

[A]frican Americans at the end of life have significantly higher rates of hospital admission, emergency department (ED) visits, and discontinuing (also known as disenrolling from) hospice care than whites, according to a new study by researchers at the Icahn School of Medicine at Mount Sinai published today by the Journal of the American Geriatrics Society.

Researchers examined whether race played a factor in rates of hospitalization, ED visits, and disenrollment from hospice. Although previous studies have found that African American patients have higher rates of hospitalization after enrolling in hospice than white patients, it was unknown if racial differences were linked to other differences in outcomes in hospice care, whether administered in an acute hospital setting or ambulatory setting, and if race plays a significant role in end-of-life care.

“While differences exist between hospice organizations in how frequently their patients are hospitalized, including time in the emergency room, and disenrollment from hospice, these patterns do not explain racial disparities between blacks and whites in hospital use and hospice disenrollment,” says Melissa Aldridge, PhD, MBA, Associate Professor and Vice Chair for Research in Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai.

Dr. Aldridge and her collaborator, Jessica Rizzuto, MPP, a student at the Icahn School of Medicine, used data from a longitudinal cohort study of Medicare beneficiaries enrolled in a national random sample of 577 hospices around the country from the National Hospice Survey from patients in active treatment until death (2009-2010). The national sample of 145,000 Medicare beneficiaries who had enrolled in these hospices at the end of life was composed of about 92 percent white patients and 8 percent black patients. Half of the hospices were for profit, and 25 percent were members of a chain of hospices. Approximately 90 percent of the patients in the study were served by hospices in an urban area. Researchers estimated the proportion of each hospice’s patients who experienced the following utilization-based outcomes from the time of their hospice enrollment to their death: one or more hospitalizations, one or more ED visits, and hospice disenrollment. They compared the unadjusted proportion of black versus white hospice enrollees with each of these outcomes.

“We found that black hospice patients were significantly more likely than white hospice patients to be admitted to the hospital (14.9 percent vs 8.7 percent), to go to the emergency room (19.8 percent vs. 13.5 percent), and to disenroll from hospice prior to death (18.1 percent vs. 13.0 percent). These patterns remained after accounting for patient illness, demographics, and type of hospice from which these patients received care,” Aldridge says. “These higher rates of emergency department use, hospital admission, and hospice disenrollment by blacks compared with whites were attributable to racial differences within hospices rather than systemic differences between hospices in these outcomes.”

The role of a hospice is to enable individuals to remain at home during the terminal phase of their illness while receiving support, pain and symptom management, and counseling for themselves and their families. These findings matter, researchers say, because higher-intensity care at the end of life may adversely impact the quality of life of hospice enrollees and their families and increase the burden on caregivers.

The data did not allow investigators to identify the reasons for hospital use and hospice disenrollment, but they said these could occur for a number of reasons, including patient and family preferences for care, patient and provider communication about the role of hospice care, availability of resources, and caregiver burnout.

Researchers say more information is needed on hospice outcomes for patients of other races, as less is known about Asian, Pacific Islander, or Native American .

“Our findings underscore the need to better understand racial disparities in outcomes after hospice enrollment,” says Dr. Aldridge. “Culturally sensitive interventions that increase understanding of hospice, address shortcomings in provider communication, and improve caregiver resources could help decrease these persistent differences in outcomes.”

Complete Article ↪HERE↩!

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Dementia Patients and Grief

 

[T]he death of a loved one is difficult for anyone, but it is a special challenge when someone in the family has dementia. It’s hard for family members to know how and when to tell the person with dementia about the death. And what should they do when the person doesn’t remember?

Coping With Losses

People with dementia have had many “little deaths” in the course of their disease — things like losing their independence and the ability to drive, read, cook, or enjoy hobbies. Memories and relationships are huge losses.  These losses are stressful for people with dementia and their families.

How people with dementia cope with loss is affected by many things, including: the stage of their dementia, their relationship to the person who has died, how often they were in contact with that person, and their personal way of grieving

Grief Process

For people without dementia, recovery from a death usually involves accepting the reality of the loss, learning to live with it, and finding a new “normal.”  For most, the pain of the loss can transform into beloved memories.  For someone with dementia this process is often impossible.

People with dementia who are grieving are often agitated and restless. They may sense that something is not right, something is missing. They may confuse one loss with another. A recent death may stimulate the memory of loss from childhood. It can be stressful for family members to decide when and how to tell them about the death of a loved one — and even how often to tell them. Repeatedly telling a person with dementia about a death can make family members’ grief more painful.

Telling About a Death

Here are some hints for telling a person with dementia about a death:

    • Tell the news as soon as possible. They will sense that something is wrong and need information to understand, even if just for that period of time.
    • If you are too emotional to talk to them, find someone else — maybe a friend or healthcare professional.
    • Choose a time to talk when the person with dementia is well rested.
    • Use short, simple sentences. Don’t give too many details; this may overwhelm them.
    • Answer questions as honestly as possible.
    • Use clear words like “died” instead of “passed away” or “at peace now.”
    • Try not to protect the person from the truth by suggesting that the person who has died is away and will return later. This can cause worry and agitation later when the person does not return.
    • You can support them with physical touch, such as a hug or holding hands.
    • Consider involving the person with dementia in funeral planning, assigning a simple task. This will help the death be more real for them. They may recognize the rituals around death and act appropriately.
    • Plan for someone to be with the person during services who can also take them out if they become agitated.

Accepting Death

Here are some ideas of ways to help the person with dementia accept the death:

    • Speak in the past tense about the person who has died. For example, “I loved Mom’s holiday cookies.”
    • Talk with them about the person who has died and express your sadness. “I sure miss Dad. He always made birthdays so fun, didn’t he, Mom? Remember when he….” Bring out pictures and tell stories if this helps their grief process.
    • Accept how often they want to talk about the person who has died—perhaps frequently, not much, or maybe not at all.

If over time they continue to ask for the person who has died, there are some things you can do. In the beginning, gently remind them that the person has died. If reminding them becomes upsetting, you can try these ideas:

    • Respond to the emotion under their words, feelings like sadness, longing, fear, distress, suspicion, anger, concern, or confusion. You can respond to what you see:
      • “You sound really frightened (or lost, or angry, etc.) to me. Let me help you with that.”
      • “You must really be missing her. Tell me what you miss most.” Share your own feelings: “I miss her, too.”
    • Check their mood at the moment. If the person is unaware and not distressed, you don’t need bring up the reality of what has happened.
    • Look for patterns in the times they ask for the person who has died. Look for an unmet need. For example, if the person who has died usually brought them coffee in the morning, the change in this routine could be distressing and remind them that their loved one is not there.
    • Use distraction only when other ways of dealing with their grief are not working.

Each family has to find what works for them, and then try to be as consistent as possible. You may want to write out a simple plan for all family members and visitors to follow.

You can be most supportive to the person with dementia if you also take care of your own needs and get support.  We encourage family members to find support to help them cope with the painful, frustrating, lonely and sad feelings that they may feel. Supporting the person with dementia takes patience, but family members should remember to be patient with themselves as well during this stressful experience.

Complete Article ↪HERE↩!

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Death Without Duality: Three Both/Ands at the End of Life

by

[D]ying, like living, is not an either/or affair. It’s a both/and. Which is part of what makes it all so maddening for the floundering human who craves the comfort of dualities, of right and wrong, of fail-proof instructions.

I was reminded of this by some of the masters this month when I had the honor of hosting the End Well symposium in San Francisco. Twenty-eight speakers took the stage and talked about their experiences of almost dying, or treating the dying, or mourning someone who has died, or caring for the caregivers, or trying to shape policy or redesign systems or teach people about dying and/or do some of these simultaneously. There was some anger, and no small amount of sadness of course, but also a surprising amount of laughter. It turns out that we are funny right to the end.

Here are three both/and axioms that I heard echoed most often from people with a hugely wide range of professional backgrounds:

1) Reckoning with one’s life at the time of death is both the simplest thing in the world and the most complex.

Buddhist teacher and co-founder of the Zen Hospice Project, Frank Ostaseski, put it beautifully:

“At the end of life, it gets really simple: Am I loved? Did I love well?”

He’s right. Those questions are incredibly simple. As are the “four things” one can say — “Please forgive me,” “I forgive you,” “Thank you,” and “I love you” — at the time of death, popularized by Ira Byock. One of the huge, unique gifts of facing the end of life — whether your own or someone you love — is that the urgency for healing is undeniable.

But the dynamics that spark and rot and flow and flutter underneath those questions are anything but simple. They are as complex as human relationships as a whole, which is to say very fucking complex. The answer to the question of whether I am loved may seem obvious to an outsider, but if I’ve never felt loved in the right way by the one person I needed it most from, I may not be capable of a “yes.” Even at the time of death, especially at the time of death, we are not logical creatures.

And to answer whether we have loved well is perhaps an even more charged and challenged task. We carry our regrets and sense of relational inadequacy around for decades and then, in the end, are asked to lay them down and surrender to our own imperfection. A tall order. The tallest perhaps. Dr. B.J. Miller, former executive director of the Zen Hospice Project and a clinician, teaches:

“If there is any enemy at the end of life it is shame.”

If we can’t shed our shame, it makes it hard to go. The power in the dying process, from what I gather from these wise souls, is acknowledging the complexity underneath or behind the simplicity and still managing to grace one another with the forgiveness and recognition that we all so desperately crave. It is the kind of emotional courage that transcends death.

2) Our job, when caring for the dying, is to ease suffering, but also recognize that it is a source of meaning for many people.

B.J. also said, “I wouldn’t wish a lack of suffering on my worst enemy. There’s no way to learn.”

He knows a bit about it, having had three limbs amputated and survived near-lethal burns on much of his body after an accident in college. His own time in hell was incredible preparation for a lifetime of treating patients and talking with people about facing death.

Some of us have an inclination to romanticize death. It’s the peak of drama, no doubt — the final scene. But of course it is not all buzzer beater catharsis and mystical visitations. It is sometimes choking and seizing and terrible, ugly, unbearable pain. In a word, suffering.

Now the role of palliative care, but all health care really, is to ease suffering. This is true and important and so often lost in our current system, which too often feeds the wrong motivations in otherwise decent and smart humans. We have to redesign the system so that easing suffering is the heart of everything we do, or as designer Ivor Williams puts it, “Death involves everyone. Design accordingly.”

And yet, B.J. Miller would not be B.J. Miller without his suffering. None of would be any of us without our suffering. It is what erodes our delusions and softens our hubris and strengthens our capacity to resist duality and blame. It is the fires in which we are all forged.

So that, too, we must remember. Which doesn’t mean easing off on pain meds, but it does mean witnessing suffering as a sacred and necessary part of being human, even as we try to work with its ferocity and sit with the one being visited at this particular moment. Or as Dr. Lucy Kalanithi, a clinician, beautiful speaker, and widow to Paul Kalanithi, author of When Breath Becomes Air, put it:

“A gift we get to have in medicine is to be witnesses. It’s a front row seat to the human condition.”

3) When you die, you are the most alone you will ever be, and yet you cannot do it well without the gift of others.

Think about it: There is no journey more solitary, by definition, than that of dying — unless you Thelma-and-Louise it. Just as you have lived in your body alone all your life — experienced its holy and wholly specific alchemy of aches and pains and pleasures — you and only you leave that body at some unpredictable moment. (As I write this, I’m reminded how otherworldly pregnancy is, a moment when women actually do, in a sense, share their solitary experience for 10 strange months.)

In any case, accepting the solitude of it is probably key to surrendering to it. You have to go it alone, at least from a purely physical sense.

And yet, to die well is to die together. Or at least surrounded by people who care for you in your time of exquisite vulnerability. Hopefully these are people who have known you at your most robust, people that you have cared for, people you have eaten and drunk too much with and laughed beside and tickled and fought with and repaired again. Hopefully these are people who know your wishes and will fight like momma bears to see them through.

In one study, 66 percent of people said that the thing they feared most at the moment of death was pain. Understandable. And not particularly surprising. Do you know what topped that fear? The fear that they would be a burden to their family members — logistically, psychologically, financially.

Dr. Aditi Mallick says, “The things that scare us the most about death are at the core of what it means to be human.” Indeed, we fear being dependent on others, being inconvenient and messy and powerless, our whole lives long. And when we die, this fear becomes epic. Our power lies in making peace with it. If we live like we will one day die, then we can’t help but create relationships that are loving and strong and imperfect and they can weather even this, the final test of the human condition.

As B.J. puts it, “The end of life is a call to learn how to be loved. The hardest thing of all.”

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