Tag: dying

Teaching about death

Dr. Jessica Zitter has both written a book and a movie about death and dying. (photo by Rikki Ward Photography)

Dr. Jessica Zitter, who works as an attending physician at a public hospital in Oakland, Calif., struggled with her job’s protocols for years. Until the day a nurse opened her eyes to the possibility that there was a better way, one that involved more compassion in the treatment of patients.

Zitter comes from a long line of doctors.

“They were into the art of medicine,” she said of the mentors she had when she first began her studies. “By that, I mean the art of surgery and intervening, and of doing things in a very precise way. There was something about that that I found heroic, and I wanted to be part of that world.

“So, I went to medical school – pulmonary and critical medicine – which I thought of as the most heroic of the specialties. I went on to start to focus on the machines, technologies, protocols and things that were part of the trade of being a pulmonary critical care physician. I tried to really perfect them … [thinking that,] if I use these perfectly, I’ll be able to help a lot of people.”

But, as she went along, she started to think differently. At first, she suppressed the feeling. “It was truly uncomfortable,” she said. “It caused me a lot of suffering.”

Zitter was using techniques and protocols on people who were not going to benefit from them, knowing full well that they would not benefit from them. Not only was she following her training, but she also wanted to please her patients – give them mainly good news and information about various procedures, instead of telling them the whole truth about their condition.

“I didn’t want to tell them, ‘Hey, I don’t think you’ll survive,’” said Zitter. “I didn’t want to say that because it’s too sad. I would communicate about things that were more practical like, if this happens, we will try this.”

A pivotal moment

Zitter’s approach changed after an encounter in the intensive care unit with a nurse from the family support team, called Power to Care.

“One day, I was about to put in a line [catheter] into someone who was really, really sick and likely dying, and the woman who headed that family support team was standing in the doorway watching…. I was about to put the needle in and she put her hand up to her face and she said, ‘Call the police,’ on a pretend telephone…. She said, ‘Call the police. They’re torturing a patient in the ICU,’” said Zitter. “And that was my epiphany moment. All these moments, I had this doubt. This was like a relief – you’re right, I am torturing the patient. What the heck? There was a clarity there that was really powerful.

“But, the sad truth is that I still put that needle in. I still put that catheter in that woman. The force of what I call the end-of-life conveyor belt is so powerful … not only the conveyor belt itself, but the drive to ‘protocolize,’ heaping on treatments … the culture in the hospital. It’s hard to break out. It’s hard to stop and take a pause, and say, ‘Wait a minute. What the heck?’”

The intervening nurse, Pat Murphy, in some ways became Zitter’s mentor on what it meant to be a doctor.

“I came to it late and from a place of profound dissatisfaction and moral distress, and I was just extremely lucky that I happened to be in one of four hospitals where this movement was starting to take hold,” Zitter told the Independent.

“And, I happened to have been open to it,” she added. She was able to get over her “human defence of not wanting to look stupid or like I didn’t understand … and to be able to say, ‘OK. Teach me.’

“I feel lucky that those two things were in check at that time,” said Zitter. “Not to say that I wasn’t filled with shame and embarrassment about what I’d been doing all that time, but the psychology…. Once you admit there’s a problem, then find a way to fix it.”

After years of immersing herself in this new paradigm, Zitter felt ready to share what she had learned. She published a book about it, called Extreme Measures: Finding a Better Path to the End of Life, in 2017.

As she was writing it, Zitter realized that, if a picture can impart a thousand words, maybe a movie would be able to convey even more. So, she put together a 24-minute documentary, Extremis.

Of the award-winning film, Zitter said, “It really shows the issues that come up in an ICU…. There is also a discussion guide that goes with it, so people can watch it and then come away from it with some lessons learned.

“This movie reaches a wide audience about really advanced care planning,” she said. “A lot of synagogues are using it, medical schools and nursing schools.”

Death education

Zitter was asked to teach sex education at both of her daughters’ schools.

“I want them to be able to make the best decisions they can make about their bodies and their health, and to be empowered to live the best they can,” she said.

But what about death education?

Extremis came out in late 2016. “It was nominated for the Oscars and a lot of my kids’ friends were watching it. And all these kids were really blown away by the movie and they were having a positive response to it,” said Zitter. “It made me think, ‘Why the heck aren’t we teaching kids about death? Why aren’t we having a conversation in high school, just like with sex ed?’ So, a friend of mine designed ‘death ed.’ We did it in her kids’ and my kids’ schools. It was really impactful.”

Zitter would love to see such a class in every school in the United States and Canada, along with other heath education classes, so everyone can have the opportunity to learn about a range of issues and discuss them.

Both the teachers and the students appreciated the lesson on death education, said Zitter. “There were no negative responses. Although some kids cried, and it was terrifying at first, they would then say, ‘That was sad, but I’m OK.’

“I was like, ‘It is sad that we are all going to die.’ But, you know what? It’s really good for these kids too, [because] it’s part of life. If we pretend no one’s going to die and don’t let our kids go to funerals, etc., we aren’t doing anyone a service.”

So far, Extremis has been translated into 90 languages and has been shown in 160 countries.

“We’ve got to tell people what’s actually happening and try to understand,” said Zitter. “I use myself as a prime example…. Why was I putting that catheter into a woman I knew was dying? What are these factors that are propelling me to do things that don’t make sense to me? The idea is to be more conscious of it, aware of it, and change it.”

For more information about the movie and the book, visit jessicazitter.com. The film trailer can be found on YouTube.

Rebeca Kuropatwa is a Winnipeg freelance writer.

On death and dying

Rabbi Laura Duhan Kaplan, director of inter-religious studies at Vancouver School of Theology. (photo from Laura Duhan Kaplan)

“Most of the world’s religions speak of dying to self,” said Dr. Eloecea, a Christian psychotherapist speaking at the Inter-Religious Conference on Spiritual Perspectives on Death and Dying at the Vancouver School of Theology May 22-24. “If we can do this before the time death approaches, suffering is greatly diminished for ourselves and for those around us.”

“Dying to self” refers to giving up egotism and self-centred attachments. Eloecea’s words echoed a theme that appeared in many of the sessions I attended, which was that of a holistic spiritual path of surrender and humility that unites life and death.

Rabbi Dr. Laura Duhan Kaplan, formerly of Or Shalom Synagogue and now director of inter-religious studies at VST, discussed how she had been spurred by reading Plato to take a closer examination of Jewish views of death and the afterlife. “Plato said living well is preparing for death. But what is death?” she asked.

Duhan Kaplan explained how the texts of kabbalah offer accounts of a soul’s journey after death. The soul travels through stages of physical, emotional, intellectual and spiritual purification, she said. According to Duhan Kaplan, this account of the afterlife is based both in kabbalistic theories of the soul’s development and glimpses of higher consciousness by current spiritual seekers. As Duhan Kaplan presented them, these texts are a guide to a lifetime of self-reflection, humility and non-attachment.

The stages of the soul’s ascent after death are tied to the rituals and rhythms of the traditional Jewish year of mourning that follows the death of a loved one, she said. “When I decided I would research Jewish views of the afterlife I had no idea I would discover what I did.”

Duhan Kaplan spoke of the dreams and spiritual experiences she had after the deaths of her father, mother and mother-in-law. She said the stages of her parents’ journeys offered particular gifts that related to their stages of spiritual ascent in the next worlds. The movement from the shivah period through the year of saying Kaddish to the yahrzeit and Yizkor corresponds to the soul’s difficulty in letting go, the emotional purification, the visit to the lower Gan Eden, the “paradise of understanding and good deeds,” and then the return to the storehouse of souls to merge with the divine. This description captures just one thread in the rich tapestry of connections Duhan Kaplan wove.

Other teachers at the conference presented different lenses through which spirituality relates to death. Acharya S.P. Dwivedi, poet and interfaith activist, presented the traditional Hindu view of karma, reincarnation and freedom from rebirth through non-attachment and identification with the transcendent self (atman). Dwivedi described how in the Hindu view the jiva (individual soul) moves from birth to death, experiencing happiness or suffering in accordance with the good and bad actions it commits, until finally it finds its true identity with the atman – the innermost self that is one with all of existence – and lets go, returning to its source and not again being reborn.

Syed Nasir Zaidi, Muslim chaplain at the University of British Columbia, discussed the importance in Islam of confronting and making peace with death. “Death should be our strength, not our weakness,” Zaidi said, emphasizing how thoroughly internalizing the reality of our own death and ceasing to fear it can enrich our spiritual path. Zaidi pointed out that, according Rumi, it is death that gives value to life, making it precious. Zaidi also explained that, in Islam, peace with death is accomplished through confident submission to God’s will in a life of virtue and acceptance of life’s unfolding as an expression of God. “Abraham told his children they should not die before becoming Muslims,” Zaidi said. “Obviously, this doesn’t refer to being members of the religion of Islam, but rather to having submitted to God, which is what being a muslim [submitted one] means.”

Some presenters offered specific practices. Eloecea shared a series of meditations aimed at producing positive thoughts to change the state of the brain, to shift from the egotistical self and its entrapping habits. Lynn Mills, a PhD student at Trinity College in Dublin, Ireland, Skyped in to present a liturgy for people in the early stages of Alzheimer’s, which consisted of psalms and prayers to be recited in their presence. This had two parts: the first was a morning liturgy for every day, the second a way to celebrate the person’s life before memory loss prevents them from knowing friends and family and remembering the stories they share.

A variety of other topics were covered. Mark Stein, a Jewish chaplain, tackled the issue of what to do when non-Christians (or anabaptists, who only baptize believing adults) are called upon to give baptisms for sick or stillborn children. Can a Jew baptize a child? Should they? Stein spoke of the need for chaplains to support people in these extreme situations. He spoke of the transformation this could cause in a chaplain, leading them not only to embrace a pragmatic flexibility but to an openness – seeing God’s work as something also happening beyond one’s own religion.

One recurrent issue was medical assistance in dying, about which there was a panel discussion moderated by Duhan Kaplan on the opening night of the conference. Rabbi Adam Rubin of Congregation Beth Tikvah spoke as a member of the panel. He noted the lack of a consensus about medically assisted dying across Jewish traditions, but affirmed a few core teachings. “First, because of the infinite preciousness of every life, we’re commanded to do everything we can to preserve life,” Rubin told the Independent. “Second, we must do everything we can to attenuate suffering. Some traditional rabbinic authorities hold that this imperative means that one can give a level of pain-killing medicine (morphine, for example) that might even endanger the life of a patient, in order to reduce the patient’s suffering. In addition, some authorities allow the removal of life-sustaining machines or apparatuses if they extend suffering, in order to allow the normal course of physical decline to take place. This is a tricky and controversial subject within Jewish tradition,” he said, “but the general idea is that there’s a place for ‘allowing nature to take its course’ if it is likely to reduce suffering. All of that said, there is a (rare for Judaism!) consensus in traditional Jewish law that it is absolutely forbidden to take one’s own life or to assist in taking someone else’s life.”

Rubin warned of the dangers of simplistic notions of consent or decision-making that don’t take into account the full range of pressures and emotional factors that might influence a person’s decision. “People are not robots, making ‘clean,’ rational decisions in a vacuum,” he said. “So, my approach, and my take on Jewish tradition, is that we must fight the things that might lead to someone wishing to end their life.”

In addition to the talks and panels, there was an afternoon session for musical and meditative reflections on the first day of the conference. Jewish music ensemble Sulam (which contains both Duhan Kaplan and her husband Charles Kaplan) performed, as did the Threshold Singers; the music was followed by Zen priest Myoshin Kate McCandless giving a presentation on meditation and chant in support of end-of-life care.

The keynote event of the conference, which was open to the public, was called We Die Alone and Yet We Don’t. It was a conversation with Dr. David Kuhl, facilitated by Duhan Kaplan. Kuhl is a professor in the department of family practice in the faculty of medicine at UBC. He helped design and develop the palliative care program at St. Paul’s Hospital, and is known for his 2011 book What Dying People Want: Lessons for Living from People Who Are Dying.

Matthew Gindin is a freelance journalist, writer and lecturer. He is Pacific correspondent for the CJN, writes regularly for the Forward, Tricycle and the Wisdom Daily, and has been published in Sojourners, Religion Dispatches and elsewhere. He can be found on Medium and Twitter.