The Last Lecture

by Randy Pausch

Pausch delivered his "Last Lecture", titled "Really Achieving Your Childhood Dreams", at Carnegie Mellon University on September 18, 2007. He gave an abridged version of his speech on The Oprah Winfrey Show in October 2007. The talk was modeled after an ongoing series of lectures where top academics are asked to think deeply about what matters to them, and then give a hypothetical "final talk", with a topic such as "what wisdom would you try to impart to the world if you knew it was your last chance?" Before speaking, Pausch received a long standing ovation from a large crowd of over 400 colleagues and students. When he motioned them to sit down, saying, "Make me earn it", someone in the audience shouted back, "You did!"

Link to Original Talk 1 hr 16 min

Link to Abbreviated 10 Minute Oprah Talk

These are worth listening to; maybe somewhat tangential to what we will cover, but classic and inspirational.

Deborah Alecson Poetry Reading

Deborah Alecson's recent Poetry Reading in Great Barrington.

On December 20, 2014, Deborah Golden Alecson read from her recently published collection of poems entitled Complicated Grief  (Finishing Line Press, 2014).  These poems were generated out of her bereavement following her mother's suicide.  

The term "complicated grief" is used to describe a grieving process that goes outside the boundaries of normal grief.  This can be the result of the psychological state of the bereaved and/or the nature of the relationship with the deceased when he or she was alive and/or a death from suicide.  

What makes the grief complicated are the plethora of emotions that are not just errupting because of a single loss, but include a cascade of frightening feelings that come from a lack of resolution or comprehension.  

In Alecson's case, the complication came not only from the shock of the suicide, but from a history of abuse from her mother.  A manifestation of complicated grief can be an inability to concentrate that can then result in an inability to work.  In her experience, she had to take a few months leave of absence from teaching.  This time was necessary for her to integrate her loss; and one of her ways she did so, was to write these poems.

Gawande's Reith Lectures

 The Reith Lectures were inaugurated in 1948 by the BBC to mark the historic contribution made to public service broadcasting by Sir John (later Lord) Reith, the corporation's first director-general.  Bertram Russell gave the first talk

This year, there are four talks by Atul Gawande.  They were presented in Boston, London, Edinburgh, and New Delhi.  All can be accessed and listened to or read.  In addition they can be downloaded for free to iTunes and transferred to an iPod for easy listening.  O! Brave New World!

You can gain access to Gawande’s four lectures at the BBC site.  They are:

Why Do Doctors Fail? Dr Atul Gawande: The Future of Medicine

1/4 Surgeon and writer Dr Atul Gawande explores the nature of fallibility in medicine.

The Century of the System Dr Atul Gawande: The Future of Medicine

2/4 Atul Gawande calls for a radical rethink of medical systems to transform healthcare.

The Problem of Hubris Dr Atul Gawande: The Future of Medicine

3/4 Atul Gawande calls for a new approach to the 'great unfixables' - ageing and death.

The Idea of Wellbeing Dr Atul Gawande: The Future of Medicine

4/4 Atul Gawande calls for a new focus on systems to ensure doctors work more effectively.

Even if you have read “Being Mortal” you will enjoy these orations.

George Bascom - Death Poems

George Bascom (1927 - 1993) was a surgeon/poet from Manhattan, Kansas.  As he was dying of prostate cancer, he penned a few poems about death which are prescient and moving.

Here's one:
Incurable

Like a weathered barn in fading fog

death out there grows steadily more clear.

The dogged feet go on to

an inexorable détente.

Hope is a little fire

that flickers with uncertain light

beneath a boundless sky.

And I beside it drift

through night and day between

the peace of stone-deep rest

and aching wakefulness.

You can more find of Bascom's death poems on Docs-Google.

A Poem for Leo

Early Thursday morning May first

I closed the circle with my father 

Of whom I am from

Honored to help

Leo’s spirit Free

From his well worn body

92 frail skin and bone

Yet still strong and courageous

Bedridden for two months

He remained a stand up guy

Offering grace and humor

Ethan visited with Leo

Understanding accepting

Sharing open hearts

Leo barely able to speak 

Offered Ethan advise

Grandfather to grandson

About the son:

“Don’t listen to him”

Leo enjoyed life long luck

He transitioned at home

His wish and my promise

We together the seven days

Of leaving his body behind

Hospice provided help

Amazing nurses aiding insight 

Meds and visits as needed

Combined with compassionate care

From Leo’s wonderful home health aides

Mark and GiGi who gave generously

Of their Warm Haitian Creole hearts

Leo walked through the only door open

Clearly and consciously seeking he stopped eating

We were together throughout this seven day journey

To his well deserved long sought release

Leaving one's body is no small task

We dressed Leo casual for comfort

Who could he still possibly need to impress?

Much to appreciate life’s life lessons

Fortunate to be born a son of Leo

Generous non-judging supportive father

Ever happy he set himself free

Japanese Death Poems

In the death poem, or jisei, the essential idea was that at one's final moment of life, one's reflection on death (one's own usually but also death in general) could be especially lucid and meaningful and therefore also constituted an important observation about life. The poem was considered a gift to one's loved ones, students, and friends. The tradition began with Zen monks, but was also popular with poets, whose poems were often just as solemn as those of monks, or entirely flippant and humorous. The poems are often full of symbols of death, such as the full moon, the western sky, the song of the cuckoo, and images of the season in which the writer died.  See also, Japanese Death Haiku.

The death poem of Basho, one of the greatest haiku poets of all time:

    On a journey, ill;

    my dream goes wandering

    over withered fields.

About the above graphic: During his last moments (September 9, 1769), Shisui's disciples requested that he write a death poem. He grasped his brush, painted a circle, cast the brush aside, and died. The circle— indicating the void, the essence of everything, enlightenment— is one of the most important symbols of Zen Buddhism. most important symbols of Zen Buddhism.

Kobayashi Issa captures mortality well in this haiku:
 

In this world 

we walk on the roof of hell,         

gazing at flowers.

  

The "R" Word

What would happen if there was "a pill that would extend your life by one day, but it cost a billion dollars, it’s unlikely that many people would argue that health insurance should pay for it. We all understand that while the benefit might be real and quantifiable, it’s not worth the expense. But what if the pill cost a million dollars? And what if it extended your life by 10 years?"

This is a fine post on a Forbidden Topic in Health Policy Debate: Cost Effectiveness.

Rationing is definitely the “R” word.

Read full blog post.

The Green House Effect

Homes for the Elderly to Thrive

by Jane Brody

NY Times, December 16, 2014

In his book, Being Mortal, Atul Gawande describes Green Houses (resident friendly nursing homes) that are the brain child of Bill and Jude Thomas.

Jame Brody devotes her weekly column on Dec. 16^th to a discussion of these innovative nursing homes that are doing no less than reinventing elder care. Their program advocates for changes that can transform the medically dominated culture of care for the elderly. Their homes for the elderly are called Green Houses.

Read Jane Brody’s essay for more information.

See Chapter 5 in Notes from Being Mortal.

How Medicare Stacks Up

U.S. Health Care Lags Worldwide for Those Over 65.

A survey of older people in 11 countries finds that U.S. adults are sicker than their counterparts abroad, as well as the most likely to have problems paying their medical bills and getting needed healthcare. U.S. adults also reported difficulty getting care in a timely fashion and using emergency departments for issues that a primary care physician could treat. Among the bright spots for the United States: having a care plan for chronic illness, and planning for end-­of-­life care.

A Conversation with Deborah Alecson

On December 11, 2014, our professor, Deborah Alecson was interviewed on NPR-WAMC by Alan Chartock.  You can listen to this fascinating discussion at: In Conversation with Deborah Golden Alecson.

You will be interested in hearing her thoughts and insights about death and dying.

Chronic Diseases Are Killing More People in Poor Countries

Chronic diseases like cancer and heart disease are rising fast in low- and middle-income countries, striking far younger populations than in rich countries and causing much worse outcomes, according to a new report.

Deaths from chronic diseases have risen by more than 50 percent in low- and middle-income countries over the past two decades, according to the report, by the Council on Foreign Relations. The increase is part of a shift in global mortality patterns in which infectious diseases, such as malaria and tuberculosis, have declined substantially and are no longer the leading cause of death in the developing world.

This article, by Sabrina Tavernise, appeared in the December 4, 2014 New York Times.  Read full article.

Hoping for a Good Death

Author and Father

by Elizabeth Reis

New York Time, December 1, 2014 

Hoping for a Good Death is an essay about the hospital death of a 78 year-old man by his daughter who teaches medical ethics at the University of Oregon.  It’s a good introduction to a discussion of advanced directives.  Dr. Reis tells us that chaotic dances of death surround even the death-beds of those who are informed.

One of the commenters recommended “the Institute of Medicine report on Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. It has plenty of data and support for making advance care planning a normal part of being an adult, no matter one's state of health.”

Dr. Reis writes: "The biggest lesson I have learned is that every family should not only discuss end-of-life wishes but should act on them by filling out an advance directive. If my father had completed one, his end might have played out differently. By the time we told the medical staff that he didn’t want to be hooked up to machines, he already was, and we acquiesced in letting things take their course, with the hope that he might improve." 

See also: KOHD post on IOM Report.

Resources

Advanced Directives: What kind of medical care would you want if you were too ill or hurt to express your wishes? Advance directives are legal documents that allow you to spell out your decisions about end-of-life care ahead of time. They give you a way to tell your wishes to family, friends, and health care professionals and to avoid confusion later on.

Caring Connections, a program of the National Hospice and Palliative Care Organization (NHPCO), is a national consumer and community engagement initiative to improve care at the end of life. Since 2004 Caring Connections has provided more than 1.7 million advance directives to individuals free of charge. Caring Connections:

• Provides free resources and information to help people make decisions about end-of-life care and services before a crisis.
• Brings together community, state and national partners working to improve end-of-life care through a national campaign called It's About How You LIVE.

Compassion and Choices: For over thirty years we have reduced people’s suffering and given them some control in their final days – even when injury or illness takes their voice. We are experts in what it takes to die well.

The Remains by Mark Strand

This is a poem about aging and death.  It is poignant and evokes deep feeling.  The poet died in November 2014 and part of the poem was printed in his NY Times Obit.

I empty myself of the names of others. I empty my pockets.
I empty my shoes and leave them beside the road.
At night I turn back the clocks;
I open the family album and look at myself as a boy.

Full Poem.

The New Old Age Blog

Paula Spann and Jane Gross, both reporters for the NY Times, run The New Old Age Blog.

"Thanks to the marvels of medical science, our parents are living longer than ever before. Most will spend years dependent on others for the most basic needs. That burden falls to their baby boomer children. The New Old Age blog explore this unprecedented intergenerational challenge."

This is a great resource.

Gabriel: A Poem

by Edward Hirsch

Never has there been a book of poems quite like Gabriel, in which a short life, a bewildering death, and the unanswerable sorrow of a father come together in such a sustained elegy. This unabashed sequence speaks directly from Hirsch’s heart to our own, without sentimentality. From its opening lines—“The funeral director opened the coffin / And there he was alone / From the waist up”—Hirsch’s account is poignantly direct and open to the strange vicissitudes and tricks of grief. In propulsive three-line stanzas, he tells the story of how a once unstoppable child, who suffered from various developmental disorders, turned into an irreverent young adult, funny, rebellious, impulsive. Hirsch mixes his tale of Gabriel with the stories of other poets through the centuries who have also lost children, and expresses his feelings through theirs. His landmark poem enters the broad stream of human grief and raises in us the strange hope, even consolation, that we find in the writer’s act of witnessing and transformation. It will be read and reread.

 New Yorker Review. 

The Median Is Not The Message

by Steven J. Gould

From the Web: Stephen Jay Gould was an influential evolutionary biologist who taught at Harvard University. He was the author of at least ten popular books on evolution, and science, including, among others, The Flamingo's Smile, The Mismeasure of Man, Wonderful Life, and Full House.

Gould's The Median Isn't the Message is the wisest, most humane thing ever written about cancer and statistics. It is the antidote both to those who say that, "the statistics don't matter," and to those who have the unfortunate habit of pronouncing death sentences on patients who face a difficult prognosis. Anyone who researches the medical literature will confront the statistics for their disease. Anyone who reads this will be armed with reason and with hope.  

PDF of Gould's classic article

Man's Search for Meaning

by Viktor Frankl

Man's Search for Meaning is a 1946 book by Viktor Frankl chronicling his experiences as an Auschwitz concentration camp inmate during World War II, and describing his psychotherapeutic method, which involved identifying a purpose in life to feel positively about, and then immersively imagining that outcome. According to Frankl, the way a prisoner imagined the future affected his longevity. The book intends to answer the question "How was everyday life in a concentration camp reflected in the mind of the average prisoner?" Part One constitutes Frankl's analysis of his experiences in the concentration camps, while Part Two introduces his ideas of meaning and his theory called logotherapy.

According to a survey conducted by the Book-of-the-Month Club and the Library of Congress, Man's Search For Meaning belongs to a list of "the ten most influential books in the United States."At the time of the author's death in 1997, the book had sold over 10 million copies and had been translated into 24 languages.

Strangely, a full text PDF version is available online.   Part One is the most important section in my opinion.

When I Am Old

by Moyra Donaldson

I'll have dewlaps and a hump and say what all the time

in a cross voice: on every one of my bony crony fingers

a ring. My lips painted with a slash of bright fuchsia,

I'll drink margaritas by the tumbler full and if my dealer

dies before I do, I'll just have to look for younger suppliers.

I can't imagine not being interested in sex, but if it happens,

so be it, really I could do with a rest, complete hormonelessness.

I may forget who I am and how to find my way home, but be

patient, remember I've always been more than a little confused

and never did have much of a sense of direction. If I'm completely

demented, I'm depending on friends: you know who you are.

"When I Am Old" by Moyra Donaldson, from Selected Poems. © Liberties Press, 2012. Reprinted with permission.

Appeared on The Writer's Almanac, November 14, 2014 (if you click on the link, you can listen to it).

Wild Messengers

Jennifer Holland’s fine article in the November 1, 2014 NY Times, is a meditation on death and grieving.  It is a personal statement that speaks to many of us.

“About a decade ago, a brain tumor came to steal my mother away. It was diagnosed after she’d exhibited a series of strange behaviors (stranger than usual, I should say, as she was a quirky lady to begin with), and she very quickly went to a dark, quiet place that none of us could reach.

Escorting a loved one through her last days wrings your heart dry. You keep smiling, helping and hugging, knowing that soon enough you’ll be able to collapse and grieve. But until then, you stay strong."

Read  Wild Messengers.

The Death of Ivan Ilych

by Leo Tolstoy

This full text eBook is for the use of anyone anywhere at no cost and with almost no restrictions whatsoever. You may copy it, give it away or re-use it under the terms of the Project Gutenberg License included with this eBook or full complete details are online at: http://gutenberg.net/license.

The Death of Ivan Ilych.

Tuesdays With Morrie

Lindsay Lincoln recommended this gem.  I read it when it first came out in 1997.  It is a memorable story that is speaks to the philosophy behind this course.

Synopsis from Wikipedia:

Newspaper sports columnist Mitch Albom recounts the time spent with his 78-year-old sociology professor, Morrie Schwartz, at Brandeis University, who was dying from amyotrophic lateral sclerosis (ALS). Albom, a former student of Schwartz, had not corresponded with him since attending his college classes 16 years earlier. The first three chapters incorporate an ambiguous introduction to the final conversation between Albom and Schwartz, a brief flashback to Albom's graduation, and an account of the events Albom experienced between graduation and the reunion with his professor. The name Morrie comes from its meaning in Hebrew (mori מורי), which means "my teacher."

Albom is a successful sports columnist for the Detroit Free Press despite his childhood dream of being a pianist. After seeing Schwartz on Nightline, Albom called Schwartz, who remembered his former pupil despite the lapse of 16 years. Albom was prompted to travel from Michigan to Massachusetts to visit Schwartz. A newspaper strike frees Albom to commute weekly, on Tuesdays, to visit with Schwartz. The resulting book is based on these fourteen Tuesdays they meet, supplemented with Schwartz's lectures and life experiences and interspersed with flashbacks and allusions to contemporary events.

When We Accept What Is

my sweet sweet Andrea

there was a lesson

to be learned

by your loss

my little baby girl

who died in your isolette

as if it were a manger

and that is not to take for granted

who I have birthed into this world

your brother who came

a year later

upon whom I bestow

all of my devotion

breaking the cycle

of harm imposed

by abusive parents

generations of them

all that is required

of motherhood

you have taught me

is to love our offspring

shower them with care

be blessed in our sons and daughters

these are the gifts

scattered beneath tragedy

waiting to be found

when we accept what is

this gold filament of grief

Deborah Golden Alecson

September 16, 2014

I Can't Go On. I Must Go On"

The title is a phrase from Samuel Beckett that appears in Paul Kalanithi's essay in the NY Times Sunday Review (Sunday, January 24, 2014): "How Long Have I Got Left?"

Kalanithi, who recently completed a neurosurgical residency at Stanford Medical Center, is used to looking at CT scans of countless patients. What he's not used to, is looking at his own, but that's what he did last year. His CT scan showed that at age 36 and never having smoked a day in his life, he had stage four lung cancer. "When I first saw my scan, I thought I didn't have very long for this world," Dr. Kalanithi said.

This NY Times reflective piece will give you much to think about.

Graphic from NY Times Essay

Deborah Alecson Podcast

Deborah Golden Alecson, a faculty member in the Schools of Health Science and Nursing, discusses a September 2014 report issued by the Institute of Medicine called “Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life.”

Alecson is faculty member in the Schools of Health Science and Nursing, an author, and one of Excelsior’s resident experts on death, dying and bereavement.

Deborah's Podcast.
Check out other links KOHD-WC to Institute of Medicine.

This is How I Want to Die

by Rabbi Jack Mpline

This essay was published on October 22, 2014 in The Jewish Forward.

Deborah Alecson writes: "This is lovely and spot-on request made by a rabbi re: his dying."

This is an edited version of the 2011 Yom Kippur sermon by Rabbi Jack Moline where he explores the condition he wants to be in at the end of his life and how best to assure that outcome.  He describes his father's series of illnesses and surgeries that enabled him to live until the age of 65, only to die of brain cancer. When reflecting on his father's suffering he is aware that ages ago we died of incurable diseases, natural events, starvation, as prey to animals, etc. Modern medical technology and advances have brought us what is too often a long drawn out dying and years of chronic illness leading up to our death. Rabbi Moline does not want to die this way. He urges each of us to talk with our loved ones about what we want at the end of our life and not to soley rely on the advanced directives that we hopefully have also put into place.  Debra Alecson

Ending Live - PBS

"Barbara Mancini was arrested and charged with helping her dying father kill himself. Anderson Cooper has her story and more on the end-of-life debate."

This is a well-done. thought-provoking report on assisted suicide.

Ending Life - PBS.

My Girl (1991)

(from IMDb) The movie is set in Madison, Pennsylvania, in the summer of 1972. Vada Sultenfuss (Anna Chlumsky) is a 11-year-old tomboy and a hypochondriac. Vada's father, Harry Sultenfuss (Dan Aykroyd), is an awkward widower who does not seem to understand his daughter, and as a result, constantly ignores her. His profession as a funeral director, in which the Sultenfuss' residence is also a funeral parlor, has led Vada to develop an obsession with death as well as disease. Vada also thinks that she killed her own mother, since her mother died giving birth to her. She regularly tends to her invalid grandmother (Ann Nelson), who suffers from Alzheimer's disease. Harry's brother Phil (Richard Masur), who lives nearby, also stops by frequently to help out the family.

Vada is teased by other girls because her best friend, Thomas J. Sennett (Macaulay Culkin), is unpopular and a boy. Their summer adventuresfrom first kiss to last farewellintroduce Vada to the world of adolescence.

Vada's summer begins well. She befriends Shelley Devoto (Jamie Lee Curtis), the new make-up artist at her father's funeral parlor, who provides her with some much needed guidance. She is also infatuated with her teacher, Mr. Bixler (Griffin Dunne), and steals some money from Shelley's trailer to attend a summer writing class that he is teaching.

But before long, things start to fall apart. Her father and Shelley start dating and get engaged, she cannot bring herself to tell her father that she has experienced her first menstrual cycle, Thomas J. dies from an allergic reaction to bee stings while looking for Vada's mood ring in the woods, and she finds out that Mr. Bixler is engaged to someone else.

Vada's grief, however, manages to mend the rift between her and her father, she learns that she didn't kill her mom during childbirth (since her father tells her that things like mothers dying in childbirth just happen), and by the end of the movie, Vada has not only managed to deal with her pain and grief, but has also overcome some of her previous issues as well.  1991, 102 munutes

Note:  This is a sweet movie about death and dying and grief.  It's light entertainment with some moving moments.  DJE

Caitlin Dougherty: Funeral Director

"Talking about death isn't easy, but mortician Caitlin Doughty is trying to reform how we think about the deaths of loved ones — and prepare for our own.

'My philosophy is honesty,' Doughty tells Fresh Air's Terry Gross. "I think that we've been so hidden from death in this culture for such a long time that it's very refreshing and liberating to talk about death in an open, honest manner."

Doughty is the founder of The Order of the Good Death, a group of funeral industry professionals, academics and artists who focus on the rituals families perform with their dead and how the industry disposes of dead bodies. She is also starting her own funeral service in Los Angeles, called Undertaking L.A., that will help families with planning after they lose a family member.

Doughty's new memoir, Smoke Gets in Your Eyes and Other Lessons from the Crematory, serves as, among other things, a way for her to cope with working with dead bodies."  This book is also available in audio format (read by the author). 

Caitlin Dougherty's Web Site.