THE NEW YORKER

Letting Go

What should medicine do when it can’t save your life?

                                                          by Atul Gawande August 2, 2010

                                                                                 An extract

                                                                                    PART 2

In the past few decades, medical science has rendered obsolete centuries of experience, tradition, and language about our mortality, and created a new difficulty for mankind: how to die.

The author recounts accompanying a hospice nurse on her visit to see patient at home…. He concludes: “I confessed that I was confused by what [the nurse] was doing. A lot of it seemed to be about extending [the patient’s] life. Wasn’t the goal of hospice to let nature take its course?

 

“That’s not the goal,” [the hospice nurse] said. The difference between standard medical care and hospice is not the difference between treating and doing nothing, she explained. The difference was in your priorities. In ordinary medicine, the goal is to extend life. We’ll sacrifice the quality of your existence now—by performing surgery, providing chemotherapy, putting you in intensive care—for the chance of gaining time later. Hospice deploys nurses, doctors, and social workers to help people with a fatal illness have the fullest possible lives right now. That means focussing on objectives like freedom from pain and discomfort, or maintaining mental awareness for as long as possible, or getting out with family once in a while. Hospice and palliative-care specialists aren’t much concerned about whether that makes people’s lives longer or shorter.

Like many people, I had believed that hospice care hastens death, because patients forgo hospital treatments and are allowed high-dose narcotics to combat pain. But studies suggest otherwise.

In one, researchers followed 4,493 Medicare patients with either terminal cancer or congestive heart failure. They found no difference in survival time between hospice and non-hospice patients with breast cancer, prostate cancer, and colon cancer. Curiously, hospice care seemed to extend survival for some patients; those with pancreatic cancer gained an average of three weeks, those with lung cancer gained six weeks, and those with congestive heart failure gained three months. The lesson seems almost Zen: you live longer only when you stop trying to live longer. When Cox was transferred to hospice care, her doctors thought that she wouldn’t live much longer than a few weeks. With the supportive hospice therapy she received, she had already lived for a year.

[The hospice nurse mentioned earlier] enters people’s lives at a strange moment—when they have understood that they have a fatal illness but have not necessarily acknowledged that they are dying. “I’d say only about a quarter have accepted their fate when they come into hospice,” she said. When she first encounters her patients, many feel that they have simply been abandoned by their doctors. “Ninety-nine per cent understand they’re dying, but one hundred per cent hope they’re not,” she says. “They still want to beat their disease.” The initial visit is always tricky, but she has found ways to smooth things over. “A nurse has five seconds to make a patient like you and trust you. It’s in the whole way you present yourself. I do not come in saying, ‘I’m so sorry.’ Instead, it’s: ‘I’m the hospice nurse, and here’s what I have to offer you to make your life better. And I know we don’t have a lot of time to waste.’ ”

Hospice has tried to offer a new ideal for how we die. Although not everyone has embraced its rituals, those who have are helping to negotiate an ars moriendi for our age. But doing so represents a struggle—not only against suffering but also against the seemingly unstoppable momentum of medical treatment.

 

You’d think doctors would be well equipped to navigate the shoals [about how to address the question of patients’ often-unrealistic life expectancy], but at least two things get in the way. First, our own views may be unrealistic. A study led by the Harvard researcher Nicholas Christakis asked the doctors of almost five hundred terminally ill patients to estimate how long they thought their patient would survive, and then followed the patients. Sixty-three per cent of doctors overestimated survival time. Just seventeen per cent underestimated it. The average estimate was five hundred and thirty per cent too high. And, the better the doctors knew their patients, the more likely they were to err.

Second, we often avoid voicing even these sentiments. Studies find that although doctors usually tell patients when a cancer is not curable, most are reluctant to give a specific prognosis, even when pressed. More than forty per cent of oncologists report offering treatments that they believe are unlikely to work. In an era in which the relationship between patient and doctor is increasingly miscast in retail terms—“the customer is always right”—doctors are especially hesitant to trample on a patient’s expectations. You worry far more about being overly pessimistic than you do about being overly optimistic. And talking about dying is enormously fraught.

PART 3 follows

                                                                        ***

 

 

 

 

Hi Friends,
suddenly a spate of activity on my blog after a silence of some weeks. Not because I've been sitting about twiddling my thumbs; au contraire!

I've written earlier, here, of the workshop for volunteer palliative care workers at Greenwich Hospital, Sydney. More recently I ran an afternoon workshop at my former college (Jansen Newman Institute, St. Leonards) for student therapists. (To see their feedback, go to maneeshajames.com/Testimonials). It was a gas facilitating that session (and amusing to see my name down as 'Lecturer' on the formal feedback form: a 'Meditation Lecturer'? -- something of an oxymoron!) 

A repeat of this workshop is due on September 20th. I've also been invited to design a meditation workshop for nurses by the head of nursing at Greenwich Hospital, and a fellow therapist has proposed a workshop for practising therapists.

All these developments are exciting -- I love teaching! -- and the challenge for me is to put all that I've gained through my years with Osho, my meditation master, into a language that is accessible to whomever I am talking, while not compromising its integrity. There are many therapeutic modalities being developed these days that utilise various facets of the meditative approach. And there are some writers, too, who combine expertise in their field with their understanding and experience of meditation, a case in point being Jon Kabat-Zinn. I've been reading (again) David Wallin's terrific book, Attachment in Psychotherapy, as he has so much to say about 'mindfulness' and therapy that I find intriguing and with which, for the most part, I agree.

So, exciting times!

 

 

Write Away!

                                                          Expressive Writing as a Healing Tool 

Waiting to see an oncologist this morning ( happily, not as a client but as a counsellor) this morning, I came across this aricle by Dr Karen Baikie, a clinical psychologist based in Sydney. It's from a magazine, Verve, for women with breast cancer...

 

 

Because emotional memories are stored as fragments in different parts of the brain (unlike factual memories), chronology and sequencing are absent, “ so we tend to remember pieces and not necessarily in the right order, which can amplify the trauma and the stress we feel from the event, because we cannot remember enough o resolve it…. When we write it tends to be in a more autobiographical form; that is, we tend to write in stories.

“So, as we disclose our thoughts and feelings related to a traumatic event, we are actually putting them into a sequence [and making them facts] ….and ultimately stripping the emotion away. Emotional writing helps us top re-organise and restructure traumatic, emotional memories. “

 

Guidelines for Expressive Writing

1)     Write in a place and at a time where you will be undisturbed

2)     Write for 20 minutes without pausing 3-5 times weekly

3)     Write by hand or computer, whichever is faster

4)     No need to worry about grammatical structure, spelling mistakes etc; the flow’s the thing!

5)     Write about whatever is troubling you – deep thoughts and feelings about an event or situation that has deeply affected you

6)     It’s fine if you write about the same event each session, or about something different each time.

7)     You may feel vulnerable afterwards. Have a friend at hand whom you can, at least, call, if needed.

 

Outcomes include…

* Fewer illness-related visits to the doctor

* Fewer days in hospital

* Reduced absenteeism from work

* Quicker re-employment after job loss

* Improved memory, and immune system functioning

* Improved moods

* Lowered blood pressure

 

For more about the originator of Expressive Writing, visit…

 

www.utexas.edu/features/2005/writing

Last week I facilitated a workshop for volunteers at Greenwich Hospital, here in Sydney: An Introduction to Meditation.

 

Through a series of very small and simple techniques, participants were given the opportunity to discover certain qualities and experiences associated with meditation: being in the present, relaxed, aware and centred; conscious ventilation; being responsive rather than reactive; and accessing our capacity to be joyful and loving, and so on.

My aim was to provide not just a lovely day which, however delightful in the moment, would be forgotten as if it had never happened some weeks down the line, but one which would also give participants a repertoire of techniques that they could take away and immediately integrate into their everyday living.

 

The feedback included appreciation of having been given an eclectic assortment of approaches. Perhaps the majority of those new to meditation have the idea that it is either about chanting a mantra (as in TM) or sitting passively, watching the breath (as in the Buddhist tradition).

The notion that any activity done with awareness is a meditation was new to most of the group, I imagine.  Probably none anticipated that as one of the methods we’d be doing a form of meditation called gibberish (and would find it to be, in fact, a fun and effective form of tension release)!

 

Some participants were overjoyed to have a day just for themselves, to nourish and rejuvenate them. We all need that, and especially, perhaps, those who – like the volunteers – are with the sick and dying.

 

A follow-up day (in fact, a morning) in a few weeks’ time will give participants an opportunity to talk about how it has been for them to introduce meditation into their everyday lives, and to discuss how to be – and remain – motivated to meditate.

Friends,
this is a wonderful clip to watch -- a short video showing Anthony Quinn, the actor who played Zorba, and Mikis Theodorakis, the Greek composer.

 

http://www.youtube.com/watch_popup?v=CKHlmb5xcq8#t=28%3E

Then you can also see the clip from the movie, Quinn with Alan Bates.

 

Friends, check out this link:
http://www.independent.co.uk/arts-entertainment/books/features/beryl-bainbridge-on-the-art-of-facing-death-2024233.html

Beryl Bainbridge on the art of facing death

Mortality was a constant theme and inspiration in the work of the author Beryl Bainbridge. In one of her final pieces of writing, she reflects on the journey from light to darkness

 

                                                     MYKEL NICOLAOU

 

We die of many things, accidents, tumours, infections, old age. There is only one way to be born, but Death has ten thousand doors for men to take their exits. Whatever the cause, life ends when the heart stops beating. To give value to existence death must be regarded as an art, which is why the great of this world are remembered with pomp and circumstance in surroundings dedicated to the worship of God. Somewhere, we are told, above the bright blue sky there is another land, one full of joy and free from pain. We are wise to believe it, for we need for sanity’s sake to disguise the alternative...a final, obliterating darkness.

 

 

 For the starving and oppressed life could be regarded as an unfortunate error, for the rest of us as a baffling mixture of needs and necessities that are seldom satisfied. It is odd that both categories fear a cessation of breath and a return to dust, even those who believe in God; but then, surely it is against nature to think that we have endured so much to arrive at nothing.

For a writer the subject of death is the one most likely to engage and enlarge the imagination. Dickens, in A Tale of Two Cities, seared history in his description of the French Revolution – “If Bedlam Gates had been flung open wide, there would not have been such maniacs as the frenzy of that night made... On the skull of one drunken lad – not twenty by his looks – who lay upon the ground, a bottle to his mouth, the lead from the roof came screaming down in a shower of liquid fire, white hot, melting his head like wax.”

When young, I learnt about dying in a children’s story entitled “On Angel’s Wings”. It was written by someone called the Hon Mrs Greene, and it told of a child named Violet who was a hunchback. Her mother kept reassuring her that one day, when Jesus came to claim her, silver wings would sprout from her damaged back. They both wept a lot, in spite of the happiness to come. Then I was exposed to the sad demise of poor Spike in Nicholas Nickleby and little Paul in Dombey and Son. Later still, the school I attended herded us in crocodile to the Liverpool Philharmonic Hall for the showing of British troops marching into what was labelled as a “Death Camp”. We watched as bulldozers scooped up bony puppets and tossed them into pits. Nothing was explained. Nobody cried.

It was the showing of this film that made me want to write books. I even started a novel about a girl being sent to Belsen, but abandoned it on the grounds that it was wrong of me to think I could possibly know what such a sentence could mean.

 

All the same, the novels that followed centred on death. In the very first one a child died, in the second two children committed a murder, in the third an elderly woman put an end to an American soldier, and in the next a clergyman killed his wife. There were several others that revolved around dying, and when I had used up the stories in my head I turned to events in history, in particular the Crimean War, the sinking of the Titanic and Captain Scott’s fatal journey to the South Pole.

This last subject was my favourite, for in researching the facts I stumbled across a friendship that astonished me.

On 10 February 1913, a search party uncovered the tent containing the bodies of Scott and his two companions. Wilson and Bowers were lying in an attitude of sleep, their sleeping bags over their faces. Scott was sitting half upright, his coat unbuttoned. There were three notebooks and some letters tucked under his armpit; they had to break his arm to retrieve them. Along with a note to his wife there was a letter addressed to J M Barrie, urging him to take care of Peter Scott, his grandson.

In my teens I was employed first as an assistant stage manager and later as an actor at the Liverpool Playhouse Theatre. When the company hadn’t a matinée we went to the Empire Theatre to watch whatever was in production. One afternoon it was J M Barrie’s Peter Pan. Which was why, so many years on, that letter under a frozen arm astonished me.

What could the creator of that strange and magnificent play about Never Never Land possibly have in common with a man whose life had been shaped by the discipline of a naval career? If Scott had died at sea or of old age and been buried in the ground, his end would have been no more than expected; but he had been buried beneath the ice and is still there, 90 years on, perfectly preserved as he drifts towards the sea. He is yet another Lost Boy who has never grown old.

It was at the Playhouse too that I was a lady-in-waiting in the court of Richard II. When I wasn’t on stage I was in the prompt corner, ready to whisper a forgotten line. Of all writers Shakespeare was one who dwelt most on death. “Cry woe, destruction, ruin and decay, The worst is death, and death will have his day.”

I still remember by heart the words in Act III when Richard faced the end to come: “For God’s sake let us sit upon the ground/ And tell sad stories of the death of kings;/ How some have been deposed; some slain in war; Some haunted by the ghosts they have deposed/ Some poisoned by their wives; some sleeping killed;/ All murdered; for within the hollow crown/ That rounds the mortal temples of a king/ Keeps death his court.....

I used to recite this in my head when running to Exchange station to catch the last train home. Then, I didn’t think such sentiments applied to me, only to those who were unlucky enough to be royal. But then, Shakespeare, in spite of being a genius, was voicing fears common to us all.

In my day, females were not encouraged to go to gravesides to watch coffins being lowered; the church service was considered harrowing enough. Dropping someone into the earth was a ritual only men could stomach without emotion getting the better of them. The first death I really remember was that of my Auntie Margo who worked in a factory, chain-smoked and liked men. She had been married but her husband, returning from the trenches of the First World War, had succumbed to the gas in his lungs. Although it was assumed she had died of a broken heart, my Dad argued that it was the cigarettes that had finished her off. She left me her sofa, her chest of drawers and a photograph of my grandfather, who had been employed coiling metal rings round barrels in a brewery.

My father died in 1971, of cardiac arrest. My mother telephoned me twice – the first call when he was being carried out into the street on a stretcher. She wasn’t with him because she couldn’t find her house keys. The second time, he’d died in the ambulance. My mother expired a good 10 years later, alone in bed, her teeth under the pillow. For the first time, visiting the funeral parlour, I saw a dead body. My mother was encased in the sort of frilly paper I associated with Easter eggs on display. The red paint on the nails of her fingers crossed piously on her chest was chipped, the little finger particularly. I stooped to kiss her and her cheek was like ice; my tear bounced back into my face. I still have her teeth, in a cardboard box beneath a picture of Napoleon.

Next to go was my brother, in his fifties. We were not alike – so I thought – for he went to university, studied law, and sang in the church choir. We hadn’t been close, although in childhood we had huddled together on the stairs listening to the violent interchanges between our parents.

His burial was in Montgomery, a village in Shropshire in which, when little, we had spent our summer holidays. There were people standing, heads bowed, outside the doors of their houses as the funeral cars drove slowly down the country roads. I couldn’t understand how my brother had become so revered. It was only when attending to the words of the vicar that I learnt that he had been both the mayor and the county coroner – that man whose job it is to know how and why someone has died. So we were alike after all, in that we both had an interest in death.

I find it odd that the onset of life, that mingling of sperms followed by that shattering expulsion from the womb, should be regarded as less interesting than its termination. In literature birth is dealt with sentimentally. Maybe it’s because babies are sweet, opening their mouths to emit that first howl, and the dead are frightening because they’re unable to cry.

In our youth, as the philosopher Schopenhauer observed, we contemplate our life like children sitting in a theatre before the curtain has risen, eagerly waiting for the play to begin. Full of high hopes, it is a blessing that we don’t know what is going to happen. Could we foresee it, there are times when we might seem like prisoners, condemned, not to death but to life, as yet all unconscious as to what such a sentence might mean.

There are some endings to life that are classified as peaceful, among them that of Dr Samuel Johnson, a man who when alive was terrified of what was to come. He had his reasons. He wrote in his collection of Prayers and Meditations that when he surveyed his past life he discovered nothing but a barren waste of time, with some disorders of the body and disturbances of the mind which he hoped God had made him suffer to excuse many faults and deficiencies. He confessed his fear to his friend, Dr Adams, Master of Pembroke. “As I cannot be sure that I have fulfilled the conditions on which salvation is granted”, he said, “I am afraid I may be one of those who shall be damned.”

Dr Adams asked him what he meant by damned. “Sent to Hell, Sir, and punished everlastingly,” answered Johnson, passionately and loudly. And yet, when his final moment came – he was in his bed in Bolt Court, watched over by his two lodgers, the servant Frances Barber whom he had rescued from slavery, and the bad tempered Mrs Desmoulins – he expired, so we are told, without panic. One assumes he no longer felt that his sins had obliterated his space in Heaven. But then, how could he be sure?

Does the slowing down of existence lead to a blurring of the brain, a loss of memory, a sensation of emptiness that is classified as a feeling of peace? Was Johnson so close to that final sleep that he was no longer conscious of the world he had once known? Had all the sins he had committed, the destructive accusations, the damning criticisms, faded into the darkness?

We can but ask, if so great a man as Johnson could be lost, which of us can be saved? Perhaps with death all his fear vanished, and the angels said to his soul, as they said to that of Gerontius, “It is because then thou didst fear, that now thou doest not fear./ Thou hast forestalled the agony, and so/ For thee the bitterness of death is past.”

I think of death a lot, indeed always have, although when young I had a belief that it was a long way off. Now, it isn’t, and I continually think of how I would prefer to pass from light to darkness. I don’t want to be run down by traffic, be shot by a madman, or suffer a sudden shock to the heart. I would like, if possible, to be so conscious of what was coming that I had time to write down a few thoughts on paper. I would remember my parents, the love I once felt for them, and for my husband who left so many years ago, and try to put into words the joy my dear children have brought me.

Animals are more content with existence than humans, and fly from death instinctively, without knowing what it is. Accordingly, their lives carry less sorrow, but also less pleasure. We, on the other hand, cherish a belief that there is another life to come. And yet, if we look at life in its small details, how ridiculous it all seems once death approaches. We should remind ourselves to the last breath that what mattered was tolerance, patience, regard and a love of a neighbour. And if we managed that, maybe we’ll find that other land.

Beryl Bainbridge (1934-2010). This essay was originally written for BBC Radio 3, and first broadcast in March 2009. Her funeral is today, at St Silas the Martyr, London NW5

 

 

 

 

 

 

 

 

 

 

 

http://www.independent.co.uk/arts-entertainment/books/features/beryl-bainbridge-on-the-art-of-facing-death-2024233.html

 

Beryl Bainbridge on the art of facing death

Mortality was a constant theme and inspiration in the work of the author Beryl Bainbridge. In one of her final pieces of writing, she reflects on the journey from light to darkness

                                                        MYKEL NICOLAOU

Counsellor - Sydney
Professional, empathic & supportiveEnrich your quality of life today.
www.LouiseFriend.com.au

We die of many things, accidents, tumours, infections, old age. There is only one way to be born, but Death has ten thousand doors for men to take their exits.

Whatever the cause, life ends when the heart stops beating. To give value to existence death must be regarded as an art, which is why the great of this world are remembered with pomp and circumstance in surroundings dedicated to the worship of God. Somewhere, we are told, above the bright blue sky there is another land, one full of joy and free from pain. We are wise to believe it, for we need for sanity’s sake to disguise the alternative...a final, obliterating darkness.

For the starving and oppressed life could be regarded as an unfortunate error, for the rest of us as a baffling mixture of needs and necessities that are seldom satisfied. It is odd that both categories fear a cessation of breath and a return to dust, even those who believe in God; but then, surely it is against nature to think that we have endured so much to arrive at nothing.

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For a writer the subject of death is the one most likely to engage and enlarge the imagination. Dickens, in A Tale of Two Cities, seared history in his description of the French Revolution – “If Bedlam Gates had been flung open wide, there would not have been such maniacs as the frenzy of that night made... On the skull of one drunken lad – not twenty by his looks – who lay upon the ground, a bottle to his mouth, the lead from the roof came screaming down in a shower of liquid fire, white hot, melting his head like wax.”

When young, I learnt about dying in a children’s story entitled “On Angel’s Wings”. It was written by someone called the Hon Mrs Greene, and it told of a child named Violet who was a hunchback. Her mother kept reassuring her that one day, when Jesus came to claim her, silver wings would sprout from her damaged back. They both wept a lot, in spite of the happiness to come. Then I was exposed to the sad demise of poor Spike in Nicholas Nickleby and little Paul in Dombey and Son. Later still, the school I attended herded us in crocodile to the Liverpool Philharmonic Hall for the showing of British troops marching into what was labelled as a “Death Camp”. We watched as bulldozers scooped up bony puppets and tossed them into pits. Nothing was explained. Nobody cried.

It was the showing of this film that made me want to write books. I even started a novel about a girl being sent to Belsen, but abandoned it on the grounds that it was wrong of me to think I could possibly know what such a sentence could mean.

All the same, the novels that followed centred on death. In the very first one a child died, in the second two children committed a murder, in the third an elderly woman put an end to an American soldier, and in the next a clergyman killed his wife. There were several others that revolved around dying, and when I had used up the stories in my head I turned to events in history, in particular the Crimean War, the sinking of the Titanic and Captain Scott’s fatal journey to the South Pole.

This last subject was my favourite, for in researching the facts I stumbled across a friendship that astonished me.

On 10 February 1913, a search party uncovered the tent containing the bodies of Scott and his two companions. Wilson and Bowers were lying in an attitude of sleep, their sleeping bags over their faces. Scott was sitting half upright, his coat unbuttoned. There were three notebooks and some letters tucked under his armpit; they had to break his arm to retrieve them. Along with a note to his wife there was a letter addressed to J M Barrie, urging him to take care of Peter Scott, his grandson.

In my teens I was employed first as an assistant stage manager and later as an actor at the Liverpool Playhouse Theatre. When the company hadn’t a matinée we went to the Empire Theatre to watch whatever was in production. One afternoon it was J M Barrie’s Peter Pan. Which was why, so many years on, that letter under a frozen arm astonished me.

What could the creator of that strange and magnificent play about Never Never Land possibly have in common with a man whose life had been shaped by the discipline of a naval career? If Scott had died at sea or of old age and been buried in the ground, his end would have been no more than expected; but he had been buried beneath the ice and is still there, 90 years on, perfectly preserved as he drifts towards the sea. He is yet another Lost Boy who has never grown old.

It was at the Playhouse too that I was a lady-in-waiting in the court of Richard II. When I wasn’t on stage I was in the prompt corner, ready to whisper a forgotten line. Of all writers Shakespeare was one who dwelt most on death. “Cry woe, destruction, ruin and decay, The worst is death, and death will have his day.”

I still remember by heart the words in Act III when Richard faced the end to come: “For God’s sake let us sit upon the ground/ And tell sad stories of the death of kings;/ How some have been deposed; some slain in war; Some haunted by the ghosts they have deposed/ Some poisoned by their wives; some sleeping killed;/ All murdered; for within the hollow crown/ That rounds the mortal temples of a king/ Keeps death his court.....

I used to recite this in my head when running to Exchange station to catch the last train home. Then, I didn’t think such sentiments applied to me, only to those who were unlucky enough to be royal. But then, Shakespeare, in spite of being a genius, was voicing fears common to us all.

In my day, females were not encouraged to go to gravesides to watch coffins being lowered; the church service was considered harrowing enough. Dropping someone into the earth was a ritual only men could stomach without emotion getting the better of them. The first death I really remember was that of my Auntie Margo who worked in a factory, chain-smoked and liked men. She had been married but her husband, returning from the trenches of the First World War, had succumbed to the gas in his lungs. Although it was assumed she had died of a broken heart, my Dad argued that it was the cigarettes that had finished her off. She left me her sofa, her chest of drawers and a photograph of my grandfather, who had been employed coiling metal rings round barrels in a brewery.

My father died in 1971, of cardiac arrest. My mother telephoned me twice – the first call when he was being carried out into the street on a stretcher. She wasn’t with him because she couldn’t find her house keys. The second time, he’d died in the ambulance. My mother expired a good 10 years later, alone in bed, her teeth under the pillow. For the first time, visiting the funeral parlour, I saw a dead body. My mother was encased in the sort of frilly paper I associated with Easter eggs on display. The red paint on the nails of her fingers crossed piously on her chest was chipped, the little finger particularly. I stooped to kiss her and her cheek was like ice; my tear bounced back into my face. I still have her teeth, in a cardboard box beneath a picture of Napoleon.

Next to go was my brother, in his fifties. We were not alike – so I thought – for he went to university, studied law, and sang in the church choir. We hadn’t been close, although in childhood we had huddled together on the stairs listening to the violent interchanges between our parents.

His burial was in Montgomery, a village in Shropshire in which, when little, we had spent our summer holidays. There were people standing, heads bowed, outside the doors of their houses as the funeral cars drove slowly down the country roads. I couldn’t understand how my brother had become so revered. It was only when attending to the words of the vicar that I learnt that he had been both the mayor and the county coroner – that man whose job it is to know how and why someone has died. So we were alike after all, in that we both had an interest in death.

I find it odd that the onset of life, that mingling of sperms followed by that shattering expulsion from the womb, should be regarded as less interesting than its termination. In literature birth is dealt with sentimentally. Maybe it’s because babies are sweet, opening their mouths to emit that first howl, and the dead are frightening because they’re unable to cry.

In our youth, as the philosopher Schopenhauer observed, we contemplate our life like children sitting in a theatre before the curtain has risen, eagerly waiting for the play to begin. Full of high hopes, it is a blessing that we don’t know what is going to happen. Could we foresee it, there are times when we might seem like prisoners, condemned, not to death but to life, as yet all unconscious as to what such a sentence might mean.

There are some endings to life that are classified as peaceful, among them that of Dr Samuel Johnson, a man who when alive was terrified of what was to come. He had his reasons. He wrote in his collection of Prayers and Meditations that when he surveyed his past life he discovered nothing but a barren waste of time, with some disorders of the body and disturbances of the mind which he hoped God had made him suffer to excuse many faults and deficiencies. He confessed his fear to his friend, Dr Adams, Master of Pembroke. “As I cannot be sure that I have fulfilled the conditions on which salvation is granted”, he said, “I am afraid I may be one of those who shall be damned.”

Dr Adams asked him what he meant by damned. “Sent to Hell, Sir, and punished everlastingly,” answered Johnson, passionately and loudly. And yet, when his final moment came – he was in his bed in Bolt Court, watched over by his two lodgers, the servant Frances Barber whom he had rescued from slavery, and the bad tempered Mrs Desmoulins – he expired, so we are told, without panic. One assumes he no longer felt that his sins had obliterated his space in Heaven. But then, how could he be sure?

Does the slowing down of existence lead to a blurring of the brain, a loss of memory, a sensation of emptiness that is classified as a feeling of peace? Was Johnson so close to that final sleep that he was no longer conscious of the world he had once known? Had all the sins he had committed, the destructive accusations, the damning criticisms, faded into the darkness?

We can but ask, if so great a man as Johnson could be lost, which of us can be saved? Perhaps with death all his fear vanished, and the angels said to his soul, as they said to that of Gerontius, “It is because then thou didst fear, that now thou doest not fear./ Thou hast forestalled the agony, and so/ For thee the bitterness of death is past.”

I think of death a lot, indeed always have, although when young I had a belief that it was a long way off. Now, it isn’t, and I continually think of how I would prefer to pass from light to darkness. I don’t want to be run down by traffic, be shot by a madman, or suffer a sudden shock to the heart. I would like, if possible, to be so conscious of what was coming that I had time to write down a few thoughts on paper. I would remember my parents, the love I once felt for them, and for my husband who left so many years ago, and try to put into words the joy my dear children have brought me.

Animals are more content with existence than humans, and fly from death instinctively, without knowing what it is. Accordingly, their lives carry less sorrow, but also less pleasure. We, on the other hand, cherish a belief that there is another life to come. And yet, if we look at life in its small details, how ridiculous it all seems once death approaches. We should remind ourselves to the last breath that what mattered was tolerance, patience, regard and a love of a neighbour. And if we managed that, maybe we’ll find that other land.

Beryl Bainbridge (1934-2010). This essay was originally written for BBC Radio 3, and first broadcast in March 2009. Her funeral is today, at St Silas the Martyr, London NW5

 

I had a conversation with Stacey – a fellow psychotherapist, formerly she was a social anthropologist – not so long ago. During it, I recall her saying that if she knew she only had a short time to live, she'd want to put all her energy into that, not give any to dying. She was happy for our exchange to be featured here....

 

I then asked her: When would you, then, be ready and willing to prepare for dying? Given that it is inevitable, and that (as you yourself said) everyone has fears around dying, isn't it only intelligent to identify and work with the issues one does have, while one is still able to? Then when one's death comes it does not need to be fraught with anguish but can be an event that one passes through with grace, and even gratitude! That's the premise on which I base all my work. Just as we consciously prepare for birth when we are pregnant – having ante-natal classes in order to understand what our bodymind will be going through in the months of pregnancy, to know what activity is good, what would not be advisable, right diet, etc, and also about breathing and panting when we are actually in labor, and how to be with the pain – why would we not, in a similar fashion, prepare for the other major transition in life? – that of dying. After all, at birth we all are already pregnant with our own death.

Stacey: Your question is a very difficult one and requires some pondering. I see death as part of the life continuum not as discreet, up until the point at which I lose consciousness, my heart stops beating etc. in which case death is a fait accompli. I wonder if, in general, we do not do better to prepare people for all aspects of living and that includes the time of living which precedes death. Certainly existential themes come to mind. It is my understanding that Buddhists prepare themselves for the moment of their death their whole life long.
Sadly our culture doesn't seem to have a similar practice. As to prenatal classes it occurs to me that nothing really prepares us for giving life and all that it entails but perhaps we can reduce our anxiety about the eminent event by attending specific classes. 

Given that our culture does not seem to help most people prepare for their death, and given that most people still have many outstanding issues that need care and attention before their death, I still think this is important work and I think many people would benefit immensely from your assistance.

Personally I would like to see the preparation for my own death as interwoven with my life, but I understand that many people would not view it this way. It also occurs to me that many people are most sensitized to death when they are young children, at mid-life and again in old age. Death is a life-cycle issue as much as any other.

Maneesha: Yes, ideally, education about dying should be part of our education, as should the fundamentals about the blob we choose to call 'living.' As you rightly observe, death is not a discrete event but is intrinsic to and interwoven throughout life, as is evident in every exhalation we make.
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I'd be interested to hear input from others about this topic – i.e Should we address the subject of death, the fact that we are all going to face it? If yes, when is the optimal time to do so and in what form?

 

 

Maneesha, Foot massage is a wonderful way to connect with another. It sounds so wonderful the openness with which you were able to connect in this way with the two patients described. I am one to love to give and receive foot massage from the time I was very young and my mother and I would practice foot massage on each other. Thank you for sharing this. : )

Dear Maneesha! I liked this article a lot. It sounds like many patients are not conscious during their last hours so all you do before that is very healing anyway. http://www.goldenbuddha.org/application/workfiles/resources/Aging.pdf Love from Dorset (UK) Zahira