A ‘Code Death’ for Dying Patients

By JESSICA NUTIK ZITTER, M.D.

Sadly, but with conviction, I recently removed breathing tubes from three patients in intensive care.

As an I.C.U. doctor, I am trained to save lives. Yet the reality is that some of my patients are beyond saving. And while I can use the tricks of my trade to keep their bodies going, many will never return to a quality of life that they, or anyone else, would be willing to accept.

Code DeathI was trained to use highly sophisticated tools to rescue those even beyond the brink of death. But I was never trained how to unhook these tools. I never learned how to help my patients die. I committed the protocols of lifesaving to memory and get recertified every two years to handle a Code Blue, which alerts us to the need for immediate resuscitation. Yet a Code Blue is rarely successful. Very few patients ever leave the hospital afterward. Those that do rarely wake up again.

It has become clear to me in my years on this job that we need a Code Death.

Until the early 20th century, death was as natural a part of life as birth. It was expected, accepted and filled with ritual. No surprises, no denial, no panic. When its time came, the steps unfolded in a familiar pattern, everyone playing his part. The patients were kept clean and as comfortable as possible until they drew their last breath.

But in this age of technological wizardry, doctors have been taught that they must do everything possible to stave off death. We refuse to wait passively for a last breath, and instead pump air into dying bodies in our own ritual of life-prolongation. Like a midwife slapping life into a newborn baby, doctors now try to punch death out of a dying patient. There is neither acknowledgement of nor preparation for this vital existential moment, which arrives, often unexpected, always unaccepted, in a flurry of panicked activity and distress.

We physicians need to relearn the ancient art of dying. When planned for, death can be a peaceful, even transcendent experience. Just as a midwife devises a birth plan with her patient, one that prepares for the best and accommodates the worst, so we doctors must learn at least something about midwifing death.

For the modern doctor immersed in a culture of default lifesaving, there are two key elements to this skill. The first is acknowledgment that it is time to shift the course of care. The second is primarily technical.

For my three patients on breathing machines, I told their families the sad truth: their loved one had begun to die. There was the usual disbelief. “Can’t you do a surgery to fix it?” they asked. “Haven’t you seen a case like this where there was a miracle?”

I explained that at this point, the brains of their loved ones were so damaged that they would most likely never talk again, never eat again, never again hug or even recognize their families. I described how, if we continued breathing for them, they would almost definitely be dependent on others to wash, bathe and feed them, how their bodies would develop infection after infection, succumbing eventually while still on life support.

I have yet to meet a family that would choose this existence for their loved one. And so, in each case, the decision was made to take out the tubes.

Now comes the technical part. For each of the three dying patients, I prepped my team for a Code Death. I assigned the resident to manage the airway, and the intern to administer whatever medications might be needed to treat shortness of breath. The medical student collected chairs and Kleenex for the family.

I assigned myself the families. Like a Lamaze coach, I explained what death would look like, preparing them for any possible twist or turn of physiology, any potential movements or sounds from the patient, so that there would be no surprises.

Families were asked to wait outside the room while we prepared to remove the breathing tubes. The nurses cleaned the patients’ faces with warm, wet cloths, removing the I.C.U. soot of the previous days. The patients’ hair was smoothed back, their gowns tucked beneath the sheets, and catheters stowed neatly out of sight.

Then, the respiratory therapist cut the ties that secured the breathing tube around the patients’ neck. As soon as the tubes were removed and airways suctioned, families were invited back into the room. The chairs had been pulled up next to the bed for them and we fell back into an inconspicuous outer circle to provide whatever medical support might be needed.

I stood in the back of the room, using hand motions and quietly mouthing one-word instructions to my team as the scene unfolded — another shot of morphine when breathing worsened, a quick insertion of the suction catheter to clear secretions. We worked like the well-oiled machine of any Code Blue team.

Of those three Code Death patients, one died in the I.C.U. within an hour of the breathing tube’s removal. Another lived for several more days in the hospital, symptoms under watch and carefully managed. The third went home on hospice care and died there peacefully the next week, surrounded by family and friends.

I would argue that a well-run Code Death is no less important than a Code Blue. It should become a protocol, aggressive and efficient. We need to teach it, practice it, and certify doctors every two years for it. Because helping patients die takes as much technique and expertise as saving lives.

Complete Article HERE!

Aid In Dying, Part 1

“I asked my audience to keep that in mind that it’s this social dimension of the dying process that gives us the best context for understanding this delicate issue. I suggested that if we kept our discussion as open-ended as possible we wouldn’t be tempted to reduce the whole affair to the single issue of assisted suicide, because that does nothing but polarize the debate.”

There was a wonderful front-page article in the February 2, 2014 edition of the New York Times titled: ‘Aid in Dying’ Movement Takes Hold in Some States. The most astonishing about the article was that, not too long ago, this sort of even-handed presentation in “the paper of record” would have been unthinkable. I’m so glad this is changing. Because, despite where you stand on the issue, no one benefits from tamping down the discussion.AidinDyingphoto_medium

I talk about assisted dying frequently. Despite being the hot button issue it is, there’s a remarkable amount of common ground amongst the varying positions if one looks for it.

I was conducting a workshop on this very topic recently and before I could really get started, a man stood up and declared: “I need to say upfront that I am diametrically opposed to assisted suicide of any kind, including physician assistance. There’s just too much room for abuse. I can’t help but think about how things would be if we started eliminating the people we think are no longer productive. You could be sure that old and disabled people would be the first to get the ax. I’m afraid the tide of this culture’s prejudice against age and infirmity would overwhelm them. It is such a slippery slope that I don’t think we ought to venture out onto it.”

Not five minutes into the workshop and I already knew it was gonna be a bumpy ride. I asked the fellow for his indulgence and asked him to allow me to continue.

death midwifeI began by saying: “It’s my experience that very few people prefer to die alone. Most dying people express a desire to have company in their dying days. And given the option, most everyone would prefer the company of friends and family to that of strangers. Very few of us have the personal strength to walk this unfamiliar territory alone. We’re social beings, after all, and there’s nothing about dying that changes that.”

I asked my audience to keep in mind that it’s this social dimension of the dying process that gives us the best context for understanding this delicate issue. I suggested that if we kept our discussion as open-ended as possible we wouldn’t be tempted to reduce the whole affair to the single issue of assisted suicide, because that does nothing but polarize the debate.

I turned to address the man who stood up at the beginning of the workshop. “I thought it curious, sir, that you took the time to assert that you are opposed to assisted suicide of any kind, including physician assisted suicide. Is that all you thought we were going talk about?”

“Well, yes, that’s exactly what I thought. Isn’t that what assisted dying means?”

“Not the way I understand it.” I said. “It’s true, acting to hasten death in the final stages of a terminal illness falls under the general heading of assisted dying, but I don’t think it defines the concept. In fact, I believe that reducing the concept of assisted dying to a single issue would be a mistake for two reasons. First and foremost, it discounts all the other more common modes of assistance regularly being given to dying people across the board. And second, this more extraordinary form of assistance is relatively uncommon. So you can see why I’m so adamant about keeping the discussion inclusive and open ended. It just wouldn’t be balanced otherwise. I believe that the issue of proactive dying can become sensationalized, distorted, and even freakish if this option is not presented as an integral part of the entire spectrum of end of life care.”assisted_dying

I think a good metaphor for what I was talking about is the midwife. Like a birth midwife, a death midwife assists and attends in a myriad of ways. A midwife is the one who is most present and available to the dying person, the one who listens, comforts, and consoles. But a midwife may also bring an array of other basic skills, like expertise in the care of the body such as bathing, waste control, adjusting the person’s position in bed, changing bedclothes, mopping the person’s brow, or keeping the person’s eyes and mouth lubricated. A midwife may also be proficient in holistic pain management and comfort care such as massage, breath work, visualization, aromatherapy, relaxation, and meditation.

A midwife may take responsibility for maintaining a tranquil and pleasing dying environment. Often this means arranging the person’s home or room, not only in terms of the practical considerations, but also in terms of the aesthetic as well. This may include arranging flowers and art, reading aloud or playing music softly. A death midwife, like a birth midwife takes the lead role in the caring for and comforting the one who is dying. Without this kind of compassionate presence, few people would have the opportunity to achieve a good death.

Another guy spoke up: “That’s all fine and good, but I was hoping that we were going to talk about, you know, the more proactive aspects of assisted dying. I mean, I know I’m gonna want help in bringing my life to a close when the time comes and no amount of breathing exercises and adjusting pillows is gonna cut it. Am I making myself clear?”

“I understand what you are saying. You want some practical advice on how to end your life if the need arises.” I responded. “I can assure you that we well get to that. I just wanted to make sure that we all appreciate the context of our discussion.”

physician aid in dyingAn elder woman in the first row raised her hand. “I’m glad that you’re taking the time to help us frame the debate in this way because I’m confused. I have the same reservations as the first gentleman who spoke, but now I’m not sure my concerns are warranted. Maybe I need more time to figure out what it is we’re talking about when you say, ‘proactive dying.’ Is it euthanasia, assisted suicide, self-deliverance, what? And why so many different terms?”

“You make a very good point, ma’am. Unfortunately, there is no agreement, even among experts, about a common vocabulary for this debate. And thus the public discourse often generates a whole lot more heat than light. And the topic of proactive dying will continue to be a hot-button issue until we can come to a consensus about the parameters of the debate, and that seems like a long way off.”

I went on to say that I have trouble with most all the terms commonly used in the debate. I consider euthanasia is much too technical. Curious enough, at one time this word meant an easy, good death. Now, unfortunately, it is defined as mercy killing, a classic example of how language can be corrupted.

I also try to avoid using the term “assisted suicide” when I talk about someone hastening his or her death in the final stages of a terminal illness. The word suicide is inappropriate in this instance, because suicide usually denotes a desperate cry for help, which is rarely if ever the case for those facing the imminent end of life.falling leaf

Finally, I don’t much like the term self-deliverance either. It’s just one of those vague, contemporary euphemisms that does nothing to clear the air. In fact, when polled, most people haven’t a clue what self-deliverance means. I prefer the simpler, more straightforward terms ‘proactive dying’ or ‘aid in dying.’

Another woman spoke up: “I’m having a hard time with this too. I mean, it’s all so confusing and there are so many subtleties to consider. I guess I’d have to say that I’m not particularly comfortable with the notion of assisted suicide or, as you call it, aid in dying. But I wonder if I’d feel differently if I were in unbearable pain. And taking someone off life support; isn’t that technically assisted dying? Where do we draw the line between what is acceptable and what isn’t? And who is going to make that determination?”

I responded: “The simple answer is that doctors and lawyers are generally the ones who make the call. That is unless individuals are granted the right to choose. But even then, medical and legal concerns can and do trump a person’s wishes.”

(We will take up this topic again next time. I’ll discuss how best to approach one’s physician about aid in dying among other things.)

Sherwin B. Nuland, ‘How We Die’ Author, Dies at 83

By DENISE GELLENE

Dr. Sherwin B. Nuland, a surgeon and author who drew on more than 35 years in medicine and a childhood buffeted by illness in writing “How We Die,” an award-winning book that sought to dispel the notion of death with dignity and fueled a national conversation about end-of-life decisions, died on Monday at his home in Hamden, Conn. He was 83.

The cause was prostate cancer, his daughter Amelia Nuland said.Sherwin Nuland

To Dr. Nuland, death was messy and frequently humiliating, and he believed that seeking the good death was pointless and an exercise in self-deception. He maintained that only an uncommon few, through a lucky confluence of circumstances, reached life’s end before the destructiveness of dying eroded their humanity.

“I have not seen much dignity in the process by which we die,” he wrote. “The quest to achieve true dignity fails when our bodies fail.”

In “How We Die, ” published in 1994, Dr. Nuland described in frank detail the processes by which life succumbs to violence, disease or old age. Arriving amid an intense moral and legal debate over physician-assisted suicide — perhaps the ultimate manifestation of the concept of a dignified death — the book tapped into a deep national desire to understand the nature of dying, which, as Dr. Nuland observed, increasingly took place behind the walls of the modern hospital. It won a National Book Award.

Dr. Nuland wrote that his intention was to demythologize death, making it more familiar and therefore less frightening, so that the dying might approach decisions regarding their care with greater knowledge and more reasonable expectations. The issue has only intensified since the book was published, and has been discussed and debated in the medical world, on campuses, in the news media and among politicians and government officials engaged in health care policy.

“The final disease that nature inflicts on us will determine the atmosphere in which we take our leave of life,” he wrote, “but our own choices should be allowed, insofar as possible, to be the decisive factor in the manner of our going.”

Beyond its descriptions of ruptured embolisms, spreading metastases and bodily functions run amok, “How We Die” was a criticism of a medical profession that saw death as an enemy to be engaged, frequently beyond the point of futility.

In chiding physicians, Dr. Nuland pointed the finger at himself, confessing that on more than one occasion he persuaded dying patients to accept aggressive treatments that intensified their suffering and robbed them of an easier death. One of those patients was his brother, Harvey, an accountant who died of colon cancer in 1990 after receiving an experimental treatment with no reasonable chance of success.

Looking back on that episode, Dr. Nuland wrote that he had mistakenly tried to give his brother hope, failing to acknowledge that disease, not death, was the true nemesis.

He was born Shepsel Ber Nudelman on Dec. 8, 1930, in the Bronx, the son of Orthodox Jews who had emigrated from Russia. (He adopted the first and middle names Sherwin Bernard when he went to kindergarten.) His childhood was spent in a tiny South Bronx apartment with his parents, his older brother, his maternal grandmother and a maiden aunt, in an atmosphere permeated with sickness and death.

A brother died before Dr. Nuland was born, and at age 3, he was hospitalized for diphtheria. His mother, the emotional center of his family, died of colon cancer when he was 11. In his memoir, “Lost in America” (2003), he recalled with striking vividness the bad smells and bloody pads that came from his mother’s room.

Dr. Nuland’s adolescent years were dominated by his father, Meyer Nudelman, a garment worker who was incapacitated by chronic illness, physical infirmities and his resistance to a new way of life. He terrified the family with his explosive rages, never learned to read or write English — Yiddish was the predominant language at home — and could not walk more than a short distance without his son’s help.

Dr. Nuland regarded him with fear and shame, emotions that would take a deep psychological toll later in his life.

While still in high school, Dr. Nuland and his older brother changed their names from Nudelman, separating themselves from a weak, angry man who, Dr. Nuland wrote, represented “everything I so desperately wanted to be rid of.” They chose a name first adopted by a cousin, Willie Nuland, a physician who looked after the boys’ parents when they were ill, and whose compassion and competence pointed Dr. Nuland toward his career.

Dr. Nuland received his bachelor’s degree from New York University in 1951 and went on to study medicine at Yale, attracted by its distance — geographically and culturally — from the old-world Jewishness in which he grew up. Reading about spinal cord diseases as a medical student, Dr. Nuland discovered that his father’s crippling illness was tertiary, or chronic, syphilis. Dr. Nuland felt anger, and then pity. “I now had some perception of the tragedy of his life,” he wrote in his memoir.

Dr. Nuland received his medical degree from Yale in 1955. Electing to specialize in surgery, he set his sights on becoming chief surgical resident at Yale-New Haven Hospital, entering a Darwinian competition for a position seldom occupied by Jews. In 1958, Dr. Nuland won the coveted appointment. Four days later, his father died of complications of syphilis. Mr. Nudelman never knew the source of what led to his father’s death.

“I think that one time, before he was married, Meyer Nudelman was very unlucky,” Dr. Nuland said in a 2003 interview with The New York Times.

Mr. Nudelman’s death fulfilled Dr. Nuland’s wish to escape his father, but instead of liberation, he felt intense guilt and shame. Plagued by feelings of unworthiness, he felt himself becoming his father, assuming Mr. Nudelman’s hunched shoulders and shuffling gait.

By his early 40s, his depression had become so severe that he was institutionalized for more than a year. Senior psychiatrists recommended a lobotomy, but they were overruled by the young resident psychiatrist who had been assigned to his case, who insisted on electroshock therapy. By early 1974, it was clear that the treatment had been a success, and as Dr. Nuland recovered, according to his memoir, he started to make peace with his father and, perhaps, himself.

Dr. Nuland’s first marriage ended in divorce. In 1977, he married Sarah Peterson, an actress and director. Besides his wife, survivors include two children from his first marriage, Victoria Jane Nuland, the assistant secretary of state for European and Eurasian affairs, and Andrew; two children from his second marriage, Amelia and William; and four grandchildren.

From 1962 until 1991, he was a clinical professor of surgery at Yale, where he also taught bioethics and medical history. He was a surgeon at Yale-New Haven from 1962 to 1992, when he retired to write full time.

Dr. Nuland’s books include “Doctors: The Biography of Medicine” (1988), “The Wisdom of the Body” (1997), “The Doctors’ Plague” (2003) and “The Uncertain Art” (2008). He was a contributing editor to The American Scholar and The New Republic.

“How We Die,” which won the National Book Award for nonfiction in 1994 and was a finalist for the Pulitzer Prize in nonfiction in 1995, has sold more than 500,000 copies worldwide. In its concluding chapter, Dr. Nuland confessed that he, like many of his readers, desired a death without suffering “surrounded by the people and the things I love,” though he hastened to add that his odds were slim. This brought him to a final question.

“And so, if the classic image of dying with dignity must be modified or even discarded,” he wrote, “what is to be salvaged of our hope for the final memories we leave to those who love us? The dignity we seek in dying must be found in the dignity with which we have lived our lives.”

Complete Article HERE!

Bringing To a Close a Long Life Together

“Each of us is entitled to intimacy and pleasure in our life, regardless of how our body looks or at what stage of life we are at. The fact that we might be sick, elder, or dying need not cut us off from these precious life-enhancing things. However, we will most likely have to take the lead in defining what it is that we need and want, and then communicate that to those who are in a position to answer our need. We ought to have confidence that this will be as enriching for partner as it will be for us.”

Clare, 73, and her husband, Charley, have been married for fifty-three years. They have four children, nine grandchildren, and five great-grandchildren. Clare’s leukemia, which was in remission for over ten years, has recurred. This time it is considered untreatable. She has decided to forego any of the heroic, life-sustaining measures for which modern medicine is so famous. She and her doctors agree that hospice is her best option. “I’ve done my homework. I’ve shopped around. I interviewed all the hospices in town and have chosen the one I feel will honor my wishes for the kind of end-of-life care I want.”

our-livesClare has lived a rich and full life. “I was a career woman long before there was such a thing as a career woman. I’ve always been a take-charge kind of gal. This leukemia may very well kill me, but it will never get the best of me.” Her illness has made her very frail. Her skin is almost translucent. She has an otherworldly look about her, but there is no mistaking her remarkably robust spirit.

Her youngest son Stan, her one and only ally in the family, brought her to our meeting. Stan says, “Oh yeah, she’s feisty all right. There’s no flies on her, and the ones that are there are paying rent.”

Clare’s biggest concern is her family. They are pressuring her to fight against death even though she doesn’t want to. She wishes that they would join her in preparing for her death rather than denying the inevitable.

“I worry about how they will manage when I’m gone. And even though I’m ready to die, I feel as though I need their permission before I can take my leave.Elderly-couple

I try to tell myself that my Charley will be just fine after I’m gone. After all he does have our four grown kids and their families to look after him. But deep down, I know how lost he’ll be without me. Even after all these years, he still needs me to help him find a missing sock!

Whenever I try talking to him about how he’ll manage when I’m gone, he gets this awful flush across his face and starts shaking like a scared little boy. It makes me feel so terrible. I feel so bad for upsetting him like that.

I’m so confused! I want to talk to Charley about all of this. He’s my husband and has been my best friend for well over fifty years, but I honestly don’t know how to reach him on this one.”

Clare straightens herself up in her chair and continues.

“Stan, here, is the only one I can talk to. Everyone else, including my husband, won’t hear a word when I start talking about planning my funeral or who will get my antique Tiffany lamp. They just say, ‘Oh, mother, stop talking like that, you’ll outlive us all.’

I know they mean well. They’re just scared and upset. But boy oh boy, it’s really getting under my skin. I know I only have a short time left to live, so I want it to be real. I’m sick of always having to smile and pretend when I’m with them. It’s about time for them to start considering my feelings for a change.”

reason to smileClare’s immediate concern and the reason for our get together is her husband Charley. She is afraid that they are drifting apart right when they need each other the most. I ask her for a little background on their intimate life together.

“I was well into my thirty’s when the woman’s movement began. It was a time of great awakenings for me. Charley was threatened, of course, but I was able to win him over in time. It was only then that our sex life started in earnest. I finally realized that sex could be about pleasure and not simply about duty. What a liberating experience that was!

Even now Charley and I are intimate, or were until the last couple of months or so. After we both turned 60 our sex wasn’t like when we were youngsters, all heated and hormonally driven, but it’s just as special. Oh, I’m so glad I am able to talk about this with you.

My main concern is the medications I’m taking for the pain. I’m woozy when I take them, but irritable without them. I want to be more available to Charley for the closeness that’s so important to each of us, but I’m often too out of it. This is a problem for Charley too, because he doesn’t know how touch me anymore. And so, I’m afraid, he keeps his distance. This only makes matters worse for the both of us.

How do I change this? Or maybe there’s no changing it. Maybe it’s just over. What a terribly sad thought that is.”

I reach out for Clair’s hand. “I am touched by the loving depiction of the intimate life you’ve had with your husband over the years. It can’t be easy for either of you to see this wind down. However, the closeness and tenderness you’ve had throughout your marriage need not stop now.eldery hands

May I ask; do you still sleep together in the same bed? Would you be comfortable initiating a little cuddling with Charley? Good! Then I’m going to suggest a regiment of spoon breathing and guided-hand touch that I’m sure will work for you both. You will, of course, need to take the lead role in this since, as you say, Charley no longer knows how to touch you, but once he gets the hang of it and he has your permission to do so, he can continue even when you’re not able to reciprocate or even respond.

Allow me to quickly explain spoon breathing. Here’s what you do; lay on your side with Charley on his side close behind you like two spoons. Then see if you can match one another’s breathing pattern. You will be amazed at how calming and comforting this will be for you both. It will also be a very effective way to reestablish a threshold for what is possible between the two of you now, in this final stage of your life.

Now the guided-hand touch; take his open hand in yours and guide it to where you like to be touched. Show him how you like to be touched where he is touching you. Long strokes, slow strokes, short strokes, soft strokes, or just having his hand rest on you, whatever. Show him the kind of pressure you are comfortable with where he is touching you. Once you’ve established a simple routine of breathing and touching, give Charley permission to carry on even if you happen to fall asleep. Because this breathing and touching technique is so gentle and loving, it should be able to serve you even as you are actively dying. But you’ll have to let Charley know that this is what you want and need. You could tell him that you want to die in his arms. What an ideal way to bring your life together to a close. Do you think Charley will accept your invitation?”

“I can’t say for sure, but I think if I suggested it to him in a way that lets him know that he would be doing it for me, it might work. But I’m not sure about what I should say.”

everyone dies“When words fail to communicate what is in your heart, you can always rely on touch. Maybe you will find that nothing needs to be said at all, Clare. Draw him close and keep him near you with touch. Something tells me Charley will find this irresistible. It could be the fondest of farewells. Something he’ll never forget.

This is my philosophy. Each of us is entitled to intimacy and pleasure in our life, regardless of how our body looks or at what stage of life we are at. The fact that we might be sick, elder, or dying need not cut us off from these precious life-enhancing things. However, we will most likely have to take the lead in defining what it is that we need and want, and then communicate that to those who are in a position to answer our need. We ought to have confidence that this will be as enriching for partner as it will be for us.”

The History of Christian Death Rites

by FREDERICK S. PAXTON

In the world in which Christianity emerged, death was a private affair. Except when struck down on the battlefield or by accident, people died in the company of family and friends. There were no physicians or religious personnel present. Ancient physicians generally removed themselves when cases became hopeless, and priests and priestesses served their gods rather than ordinary people. Contact with a corpse caused ritual impurity and hence ritual activity underworld ferrymanaround the deathbed was minimal. A relative might bestow a final kiss or attempt to catch a dying person’s last breath. The living closed the eyes and mouth of the deceased, perhaps placing a coin for the underworld ferryman on the tongue or eyelids. They then washed the corpse, anointed it with scented oil and herbs, and dressed it, sometimes in clothing befitting the social status of the deceased, sometimes in a shroud. A procession accompanied the body to the necropolis outside the city walls. There it was laid to rest, or cremated and given an urn burial, in a family plot that often contained a structure to house the dead. Upon returning from the funeral, the family purified themselves and the house through rituals of fire and water.

Beyond such more or less shared features, funeral rites, as well as forms of burial and commemoration, varied as much as the people and the ecology of the region in which Christianity developed and spread. Cremation was the most common mode of disposal in the Roman Empire, but older patterns of corpse burial persisted in many areas, especially in Egypt and the Middle East. Christianity arose among Jews, who buried their dead, and the death, burial, and resurrection of Jesus were its defining events. Although Christians practiced inhumation (corpse burial) from the earliest times, they were not, as often assumed, responsible for the gradual disappearance of cremation in the Roman Empire during the second and third centuries, for common practice was already changing before Christianity became a major cultural force. However, Christianity was, in this case, in sync with wider patterns of cultural change. Hope ofsalvation and attention to the fate of the body and the soul after death were more or less common features of all the major religious movements of the age, including the Hellenistic mysteries, Christianity, Rabbinic Judaism, Manichaeanism, and Mahayana Buddhism, which was preached as far west as Alexandria.

Early Christian Responses to Death and Dying

In spite of the centrality of death in the theology and spiritual anthropology of early Christians, they were slow to develop specifically Christian responses to death and dying. The most immediate change was that Christians handled the bodies of the dead without fear of pollution. The purification of baptism was permanent, unless marred by mortal sin, and the corpse of a Christian prefigured the transformed body that would be resurrected into eternal life at the end of time. The Christian living had less need than their neighbors to appease their dead, who were themselves less likely to return as unhappy ghosts. Non-Christians noted the joyous mood at Christian funerals and the ease of the participants in the presence of the dead. They observed how Christians gave decent burials to even the poorest of the poor. Normal Roman practice was to dump them in large pits away from the well-kept family tombs lining the roads outside the city walls.

catacombs

The span of a Christian biography stretched from death and rebirth in baptism, to what was called the “second death,” to final resurrection. In a sense, then, baptism was the first Christian death ritual. In the fourth century Bishop Ambrose of Milan (374–397) taught that the baptismal font was like a tomb because baptism was a ritual of death and resurrection. Bishop Ambrose also urged baptized Christians to look forward to death with joy, for physical death was just a way station on the road to paradise. Some of his younger contemporaries, like Augustine of Hippo, held a different view. Baptism did not guarantee salvation, preached Augustine; only God could do that. The proper response to death ought to be fear—of both human sinfulness and God’s inscrutable judgment.

This more anxious attitude toward death demanded a pastoral response from the clergy, which came in the form of communion as viaticum (provisions for a journey), originally granted to penitents by the first ecumenical council at Nicea (325), and extended to all Christians in the fifth and sixth centuries. There is, however, evidence that another type of deathbed communion was regularly practiced as early as the fourth century, if not before. The psalms, prayers, and symbolic representations in the old Roman death ritual discussed by the historian Frederick Paxton are in perfect accord with the triumphant theology of Ambrose of Milan and the Imperial Church. The rite does not refer to deathbed communion as viaticum, but as “a defender and advocate at the resurrection of the just” (Paxton 1990, p. 39). Nor does it present the bread and wine as provisions for the soul’s journey to the otherworld, but as a sign of its membership in the community of the saved, to be rendered at the last judgment. Thanks, in part, to the preservation and transmission of this Roman ritual, the Augustinian point of view did not sweep all before it and older patterns of triumphant death persisted.

However difficult the contemplation (or moment) of death became, the living continually invented new ways of aiding the passage of souls and maintaining community with the dead. In one of the most important developments of the age, Christians began to revere the remains of those who had suffered martyrdom under Roman persecution. As Peter Brown has shown, the rise of the cult of the saints is a precise measure of the changing relationship between the living and the dead in late antiquity and the early medieval West. The saints formed a special group, present to both the living and the dead and mediating between and among them. The faithful looked to them as friends and patrons, and as advocates at earthly and heavenly courts. Moreover, the shrines of the saints brought

viaticum

people to live and worship in the cemeteries outside the city walls. Eventually, the dead even appeared inside the walls, first as saints’ relics, and then in the bodies of those who wished to be buried near them. Ancient prohibitions against intramural burials slowly lost their force. In the second half of the first millennium, graves began to cluster around both urban and rural churches. Essentiallycomplete by the year 1000, this process configured the landscape of Western Christendom in ways that survive until the present day. The living and the dead formed a single community and shared a common space. The dead, as Patrick Geary has put it, became simply another “age group” in medieval society.

Emergence of a Completely Developed Death Ritual in the Medieval Latin Church

However close the living and dead might be, it was still necessary to pass from one group to the other, and early medieval Christians were no less inventive in facilitating that passage. The centuries from 500 to 1000 saw the emergence of a fully developed ritual process around death, burial, and the incorporation of souls into the otherworld that became a standard for Christian Europeans until the Reformation, and for Catholics until the very near present. The multitude of Christian kingdoms that emerged in the West as the Roman Empire declined fostered the development of local churches. In the sixth, seventh, and eighth centuries, these churches developed distinctive ritual responses to death and dying. In southern Gaul, Bishop Caesarius of Arles (503–543) urged the sick to seek ritual anointing from priests rather than magicians and folk healers and authored some of the most enduring of the prayers that accompanied death and burial in medieval Christianity. Pope Gregory the Great (590–604) first promoted the practice of offering the mass as an aid to souls in the afterlife, thus establishing the basis for a system of suffrages for the dead. In seventh-century Spain, the Visigothic Church developed an elaborate rite of deathbed penance. This ritual, which purified and transformed the body and soul of the dying, was so powerful that anyone who subsequently recovered was required to retire into a monastery for life. Under the influence of Mosaic law, Irish priests avoided contact with corpses. Perhaps as a consequence, they transformed the practice of anointing the sick into a rite of preparation for death, laying the groundwork for the sacrament of extreme unction. In the eighth century, Irish and Anglo-Saxon missionary monks began to contract with one another for prayers and masses after death.

All of these developments came into contact in the later eighth and ninth centuries under the Carolingian kings and emperors, especially Charlemagne (769–814), but also his father Pepin and his son Louis. Together they unified western Europe more

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successfully around shared rituals than common political structures. The rhetoric of their reforms favored Roman traditions, and they succeeded in making the Mass and certain elements of clerical and monastic culture, like chant, conform to Roman practice whether real or imagined. When it came to death and dying, however, Rome provided only one piece of the Carolingian ritual synthesis: the old Roman death ritual. Whether or not it was in use in Rome at the time, its triumphant psalmody and salvation theology struck a chord in a church supported by powerful and pious men who saw themselves as heirs to the kings of Israel and the Christian emperors of Rome. Other elements of their rituals had other sources. Carolingian rituals were deeply penitential, not just because of Augustine, but also because, in the rough-and-tumble world of the eighth and ninth centuries, even monks and priests were anxious about making it into heaven. Although reformers, following Caesarius of Arles, promoted the anointing of the sick on the grounds that there was no scriptural basis for anointing the dying, deathbed anointing came into general use, often via Irish texts and traditions. Carolingian rituals also drew liberally on the prayers of Caesarius of Arles and other fathers of the old Gallican and Visigothic churches.

The ritual experts of the Carolingian age did not just adapt older rites and provide a setting for their synthesis, however; they made their own contributions as well. In his classic 1908 study on ritual, the anthropologist Arnold van Gennep was surprised by the lack of elaboration of the first phase of death rites in the ethnographic reports he studied. People generally ritualized burial and commemoration, but gave little attention to the dying. Unlike other rites of passage, few rituals prepared people for death. Familiarity with European Christian traditions may be the source of van Gennep’s surprise, for well-developed preliminal rites are one of their most characteristic features. Around the year 800 certain clerical communities introduced a ritual for the death agony. To aid the dying through the struggle of the soul’s exit from the body, the community chanted the names of the denizens of paradise. Rhythmically calling on the Trinity, Mary, the angels, the prophets and patriarchs, the martyrs and confessors, and all living holy men and women, they wove a web of sung prayer to aid the soul’s passing. This practice quickly became part of a common tradition that also included rites of penance, absolution, anointing, and communion, each of which helped cut the ties that bound the dying to this world, ritually preparing them for entry into paradise.

LazarusLike most human groups, Christians had always used rites of transition to allay the dangers of the liminal period after death before the corpse was safely buried and the soul set on its journey to the otherworld. The same was true of post-liminal rites of incorporation, which accompanied the body into the earth, the soul into the otherworld, and the mourners back into normal society. But medieval Christians placed the ritual commemoration of the dead at the very center of social life. Between 760 and 762, a group of churchmen at the Carolingian royal villa of Attigny committed themselves to mutual commemoration after death. Not long afterward, monastic congregations began to make similar arrangements with other houses and with members of secular society. They also began to record the names of participants in books, which grew to include as many as 40,000 entries. When alms for the poor were added to the psalms and masses sung for the dead, the final piece was in place in a complex system of exchange that became one of the fundamental features of medieval Latin Christendom. Cloistered men and women, themselves “dead to this world,” mediated these exchanges. They accepted gifts to the poor (among whom they included themselves) in exchange for prayers for the souls of the givers and their dead relatives. They may have acted more out of anxiety than out of confidence in the face of death, as the scholar Arno Borst has argued, but whatever their motivations, their actions, like the actions of the saints, helped bind together the community of the living and the dead.

The Carolingian reformers hoped to create community through shared ritual, but communities shaped ritual as much as ritual shaped communities, and the synthesis that resulted from their activities reflected not just their official stance but all the myriad traditions of the local churches that flowed into their vast realm. By the end of the ninth century a ritual process had emerged that blended the triumphant psalmody of the old Roman rites with the concern for penance and purification of the early medieval world. A rite of passage that coordinated and accompanied every stage of the transition from this community to the next, it perfectly complemented the social and architectural landscape. Taken up by the reform movements of the tenth and eleventh centuries, this ritual complex reached its most developed form at the Burgundian monastery of Cluny. At Cluny, the desire to have the whole community present at the death of each of its members was so great that infirmary servants were specially trained to recognize the signs of approaching death.

The Modern Ageextreme-unction

Christian death rituals changed in the transition to modernity, historians like Philippe Ariès and David Stannard have detailed in their various works. But while Protestants stripped away many of their characteristic features, Catholics kept them essentially the same, at least until the Second Vatican Council (1962–1965). Like the Carolingian reformers, the fathers of Vatican II moved to restrict ritual anointing to the sick, but they may be no more successful in the long run, for the symbolic power of anointing as a rite of preparation for death seems hard to resist. And while the secularization of society since the 1700s has eroded the influence of Christian death rites in Western culture, nothing has quite taken their place. Modern science and medicine have taught humankind a great deal about death, and about how to treat the sick and the dying, but they have been unable to give death the kind of meaning that it had for medieval Christians. For many people living in the twenty-first century death is a wall against which the self is obliterated. For medieval Christians it was a membrane linking two communities and two worlds. In particular, Christian rites of preparation for death offered the dying the solace of ritual and community at the most difficult moment in their lives.

Reconnecting with the Past

The Chalice of ReposeThe Chalice of Repose Project at St. Patrick Hospital in Missoula, Montana, is applying ancient knowledge to twenty-first-century end-of-life care. Inspired in part by the medieval death rituals of Cluny, the Chalice Project trains professional music thanatologists to serve the physical, emotional, and spiritual needs of the dying with sung prayer. With harp and voice, these “contemplative musicians” ease the pain of death with sacred music—for the dying, but also for their families and friends and for the nurses and doctors who care for them. While anchored in the Catholic tradition, music thanatologists seek to make each death a blessed event regardless of the religious background of the dying person. Working with palliative physicians and nurses, they offer prescriptive music as an alternative therapy in end-of-life care. The Chalice of Repose is a model of how the past can infuse the present with new possibilities.

Complete Article HERE!

With a little help from my friends

“I was just sitting here thinking about what would be on my mind if I were in your place, facing my imminent death. I suppose I would be thinking about immortality, not in any conventional sense of that word, but more in terms of my legacy. I guess I’m really self-conscious, or maybe it’s vanity, I don’t know, but I think I’d be wondering about my contribution to this wounded world.”

My good friend Kim called me out of the blue. She asked if I would be available to consult with a couple of her friends, James and Rebecca. James is dying.

I didn’t know Rebecca or James personally, but I had heard a lot about them from my friend Kim. I talked to Rebecca briefly by phone and accepted an invitation to visit with them the very next day. When I arrived at their home, I found James very close to death. The scene was calm and, at first glance, everything seemed to be in order, but the tranquility was deceptive.

challenges aheadRebecca began by telling me that she thought something was wrong. “What do you mean, wrong?” I asked.

“I don’t know. I can’t put my finger on it exactly. James has been actively dying for weeks. Why is it taking so long? We’ve prepared for the end in the best way that each of us knows how, both psychologically and physically. Everyone has been extremely helpful. Hospice has been wonderful. But we never thought it would turn out to be such a marathon. We’ve been waiting and waiting for what seems like forever for the end but it doesn’t happen.”

She went on to say, “Don’t misunderstand, I’m not impatient for James to die, but there’s something unnerving about all of this that has us both on edge. It’s like standing at the airport fully packed for a long trip waiting to board a flight that never arrives. It’s been exhausting for the both of us. I can’t help but think we’ve overlooked something. I’ve quizzed James about it, but he doesn’t know what it could be either. That’s when Kim suggested we talk to you. We’re both afraid that our impatience and anxiety is going to disrupt the tranquility we’ve worked so hard to achieve. Can you help us?”

James confirmed what Rebecca told me. “Look at me! There’s nothing left that works, I can barely see anymore. It’s pathetic. I should have been dead by now. Even my hospice people are surprised that I’m lingering. I think I’ve been extremely patient so far, but this is ridiculous. I want this to be over, damnit. I don’t know how much more of this I can take.”

There was a blockage, no doubt about it. I could feel it all around me. Had they overlooked something important? I thought I’d better try and find out.

“James, is there anything left undone? Did your restaurant sell?”solutions

“Yeah, months ago. I’m satisfied that we’ve taken care of every last legal detail. I’ve even had two different lawyers sign off on the deal.”

“How about family; any unfinished business there?

“No, my parents are here, sisters and brothers have all been through here at one time or another. I’m feeling real good about all of my relationships.”

I was stumped. They appeared to have thought of everything. Nothing seemed out of place. So why did we all feel on edge? We sat quietly for a while and then I said, “You know, James, maybe it’s something metaphysical.”

“You mean like God and heaven and that sort of thing?”

“Yeah, in a roundabout sort of way. I was just sitting here thinking about what would be on my mind if I were in your place, facing my imminent death. I suppose I would be thinking about immortality, not in any conventional sense of that word, but more in terms of my legacy. I guess I’m really self-conscious, or maybe it’s vanity, I don’t know, but I think I’d be wondering about my contribution to this wounded world. Since I think about this a lot and I’m not sick, I’m sure that I’d be concerned about it as I lay dying. We’re not such different people, you and I. Do you ever wonder about the impact you’ve had on your world? Is any of this even making any sense?”

Silence. Then tears pooled in his eyes.

“You know, I’ve been a foodie all my life. When I moved to the Bay Area thirty years plus ago it was because it’s the center of the food world. All the world’s greatest cuisines come together here. It’s the culinary Mecca. This town really appreciates the creativity and art involved in cooking. I’ve had the good fortune to work with the best chefs in the world and, in turn, they’ve shared my table. I was good; I mean I was real good. And now that I’m dying, no one has asked me for my recipes. Was it all for nothing?”

I get by with a Little help from my friendsWe were all stunned by what we were hearing. Rebecca spoke first.

“Sweetheart, your friends would never think to ask you for your recipes. They all secretly covet them, of course, but asking for them would be out of the question. It would be kind of ghoulish, don’t you think? Like vultures hovering, waiting to pick over a carcass. And you have to admit that you haven’t been particularly forthcoming about any of this yourself.”

“Yeah, I know, but I’m dying. It’s different now. It’s my legacy, just like Richard said.”

Two days later a simple but elegant ritual had been prepared. Champagne was chilled, a couple of friends were called, and James directed Rebecca to fetch his treasure. Choking back tears of gratitude, he blessed us all.

“Thanks for making this such a great ride, you guys.”

As he said this, he handed each of us a memory stick, which held the booty. James entrusted us with his cookbook manuscript in the hopes that we would have it published after his death. He insisted that the title be: Food to Die For. We promised that we would do our best and thanked him for his trust and friendship.

I guess that took care of that, because seven hours later James was dead.