Self-expression is rarely easy for patients because words often cannot articulate how patients feel inside. Children are often asked to draw pictures in order for psychologists to gain insight into perceptions surrounding particular life experiences. Paul, a 57-year-old patient with a provocative and morbid sense of humor, stunned the ER staff with a tattoo on his left forearm depicting how he felt on the day he had a heart attack (05/08/2004). This was a day marked in infamy and a declarative moment of Paul’s legacy: My heart’s been stabbed, but my spirit remains defiant.
While laughing in the face of danger and standing before the grim reaper, Paul’s mockery of death was lighthearted and balanced. His ability to wrap his head around having a heart attack with a twisted sense of humor was actually an effective coping mechanism that offered an inspiring message. Others can easily identify and become uplifted by Paul’s apparent vulnerability and survivability. While possibly taunting the grim reaper, Paul clearly allowed this satanic force to get under his skin and permeate his being.
Male ego prompts the slogan, Never let them see you sweat. Each of us is threatened by our own mortality and a predictable sense of betrayal by our bodies. Naturally, one of the major organs is destined to fail and ultimately be the cause of our own death. As unsettling as this may seem, we still have the ability to maintain composure. We can make the best of a bad situation while not allowing devastation to get the better of us. The real crime of passion, stirred by betrayal, is allowing anger to become passive aggressive and self-sabotaging.
While dissecting and digesting this tattoo, Paul mentioned that his cardiologist was particularly drawn to the gross anatomy and attention to detail that the artist gave to the image of the heart. A heart attack can be both a real life situation and a spiritual awakening. In Anatomy of the Spirit: The Seven Stages of Power and Healing, Caroline Myss, Ph.D. brilliantly describes how the seven sacred chakras are integral to understanding the mind-body relationship. The more mindful and in tune we are with our bodies, the more we hear our hearts speak. This “intuition” releases the tension inherent to living and unleashes the power to heal.
Tattoos might be seen as a form of self-mutilation – self-mutilation understood as an intentional release of psychological stress. While some people often feel that self-mutilation represents a danger to self, others find mortification of the flesh sanctifying. Through wearing his wounded heart on his sleeve, similar to the stigmata, Paul proclaimed himself to be the sacrificial lamb representing all who are at the mercy of the grim reaper. Once the grim reaper ultimately removes the stake from Paul’s heart, his life will end. In the meantime, he has continued to live his life fully through the gift of self-expression and by leaving a lasting impression on others through his spiritual revelation.
This New Year is the appropriate time to make a resolution; the occasion to link advance care planning with a spiritual legacy. People all have deep-seated values and determinations of what they are willing to pay for, live for and die for, but few actually document these for caregivers or posterity. Beginning in 2016, Medicare will begin to reimburse physicians for end-of-life counseling. However, throwing taxpayer dollars at no-win situations is potentially invaluable or a waste of money. This New Year presents the opportunity for a change of heart – a winning formula that promotes have it your way at the end of life. Successful people are often spiritually motivated to achieving their goals. Interestingly, a documented goal is much more likely to be attained, becoming a lifelong affirmation.
A gut-wrenching situation occurred during a conversation I had with a 49-year-old gentleman whose heart was failing. He was once a martial arts enthusiast, but at the time was experiencing significant liver bloating due to fluid congestion. His heart had been severely weakened due to a septal defect and his only hope for survival was to undergo a heart transplant. In reality, his heart was not in it to win it and he essentially wished to stay alive in order to spare his 83-year-old mother the pain of having to endure the loss of another child. This predicament prompted me to consider the spiritual repercussions of my having a heart transplant. Would I discard my heart and entrust my soul to the healthcare system for the chance to sustain my life?
Self-preservation is a powerful primal instinct, while death and dying might be considered a contest between human nature and spiritual existence. With the new-found perspective being given to end-of-life counseling, it is important to not default to the time-old conversation that involves a menu of sickening choices. Given the opportunity to create a spiritual legacy beyond advance care planning, a majority of patients may prefer to be enlightened about the sweet surrender available on the dessert menu. This type of spiritual craving grants people permission to indulge themselves in dying, providing the upper hand through engaging the higher power of the heart’s good conscience. Enlisting good conscience over fear mongering during end-of-life counseling fosters a spiritual legacy that moves beyond wishful thinking.
If you ask not what your physician can do to keep you alive, ask what you can do to die peacefully, you will quickly learn that most physicians have very little practical experience with helping people die. A majority of patients’ lives end through extreme exhaustion rather than personal empowerment. A physician will often turn a blind eye to patients in the throes of dying, feeling morally and legally obliged by high expectations and impositions of caregivers. Furthermore, physicians have seemingly evolved from being humanitarians to having become effective team players and business people. Wishful thinking in regard to the personal relationship between patient and physician has truly become a forgone conclusion in what is quickly becoming the lost art of medicine.
Good conscience rightfully informs caregivers that medical intervention becomes unnecessary and inappropriate once a patient becomes incapacitated. However, all too few believe that withholding or withdrawing treatment in these situations may actually be conscientious and ethical. When grief and sorrow abound at the end of life, pity often overtakes good conscience and granting patients end-of-life wishes becomes more guarded. Advance care planning essentially permits caregivers to never need to say you’re sorry to loved ones and promotes letting go, allowing a patient’s personal destiny and pre-determined spiritual legacy to manifest.
Reflecting on the potential inherent to the New Year through creating a life resolution is heartening and just might ignite celebratory fireworks. The brilliance of a spiritual legacy as reflected in fireworks is a reminder that what goes up must come down. A spiritual legacy as a matter of the heart involves listening to the desires of the heart that prompt peaceful resolution. Dare to dream and dare to do or die from the power vested in your heart, not in the medico-legal system. Purposely resolve to document your wishes in writing. Guidelines lessen and resolve conflict, leading to happily ever after and the feeling that wishes really do come true. Peace begins with having wishes to die for as a spiritual legacy and New Year’s resolution in 2016.
I was inspired by headline posted online by the Los Angeles Times: Pope’s decree on abortion may signal change in practice. The article referenced Pope Francis’ compassion for women who have had abortions with these words: “I am well aware of the pressure that has led them to this decision. I know that it is an existential and moral ordeal. I have met so many women who bear in their heart the scar of this agonizing and painful decision.” I presume healing this battle scar through forgiveness whitewashes the soul of guilt.
The decision to end life is typically a no-win situation and often a matter of self-defense. However, it is not without the consequence of guilt. Traditional Catholic teaching considers abortion and euthanasia mortal sins with no exception. However, most Christians will recall one exception God “euthanized” his only Son for the greater good. What followed three days later was the highly proclaimed Resurrection. Resurrection or resurgence essentially begins life anew without guilt. Clearing a path to be able to walk in the light of redemption is cause for celebration.
In honoring the values of compassion and redemption, Pope Francis has proclaimed a special Jubilee Year beginning on December 8. These particular holy years usually take place every 25 years and the last one occurred in 2000. However, popes have God’s authority to offer forgiveness as they see fit and in a timely manner. During this so-titled Holy Year of Mercy, redemption may be obtained by visiting St. Peter’s Basilica in Rome. This guilt-free vacation seems like a win-win. Confusing, right?
The same confusion regarding the end of life being guilt-free is nearly impossible without forethought given to these no-win situations. Guilt-ridden patients, family members and healthcare providers plague my practice of emergency medicine and compromise mercy being given to those near the end of life. I share the grief of all who fail to rest in peace due to churches’ teachings. Grief is naturally compounded by guilt through incessant thoughts and existing doubts that not enough is being done to amend a given no-win situation.
The Catholic Church has been notorious for leading from behind on matters of sin by offering forgiveness rather than getting out in front of matters of guilt through teaching awareness. Human beings have a God-given right to free choice during no-win situations that might necessitate ending life. Having outlawed abortion or euthanasia as going against God’s will is presumptuous and arrogant. In my practice of awareness, I believe no-win situations are amended through creating personal wins. Redemption might be perceived as doing something rewarding for oneself or others.
The new beginning inherent to this Jubilee Year supports my vision for the end of life as being a celebration. When all else fails, it’s time to pull out all the stops and alleviate the suffering triggered by guilt. This type of resurgence occurs from all who proclaim, This is the day the LORD has made, let us rejoice and be glad in it (Psalm 118:24). My fervent undertaking and inherent message is the decree of Wishes To Die For. This end-of-life perspective preempts guilt and offers peace for the dying and their survivors.
T’is the season to reflect on vitality, seemingly igniting the skies during these darkest days that commence a new era. Vitality equals dignity and is relative to the notion that we matter even when we do not measure up. The most captivating illustration of this is the Charlie Brown Christmas tree. We stand in awe of annual Christmas trees at Rock Center or the Washington Mall, but remember the Charlie Brown Christmas tree as the most loveable, primarily due to it being indifferent to its surroundings. It did not try to be something it was not and was not looking for a Christmas ornament. Its vitality or get–up and go did not necessarily get-up and went, it stayed put and continued to be counted in an unassuming manner.
The liveliness of the Charlie Brown Christmas tree did not arise from pretentiousness, but through a heart-centered indifference rooted in its core. Homage is given to the biblical passage of the meek will inherit the earth, but preference is given to being noticed upon entering a room. A newborn never seeks to be noticed or loved, yet melts the heart of everyone in the room. The infant is instinctively lovable through his or her indifference. Oddly, we need this infant to love us more than the infant needs our love. Truly, the meek inherit from the earth an organic indifference, fortifying their vitality and lovability.
Organizations like Compassion & Choices and the Conversation Project are less about life and death and more about the vitality of individuals being appreciated in an indifferent, transcendent light of lovability. Vitality is not necessarily a mindset or found in gift sets, but is a manifestation of the heart. There is tendency to adorn people with countless ornaments and interventions at the end of life similar to the over-exuberance of decorating a Christmas tree with an abundance of gifts underneath. Most people would prefer less tinsel that shines from life-support machines and more splendor that arises from simplicity. Simplicity is inspirational, fortified, dignified, indifferent and peaceful. Pomp and circumstance becomes tacky and dismal when overdone. Similarly, a neighbor’s Christmas extravaganza displays more of a need to win praise than desire for peace on earth.
Vitality through indifference wants for nothing. People are generally encouraged to want things, both at Christmas and the end of life. Wishes push for us to anticipate having a holly, jolly Merry Christmas and to not pout or be like Scrooge. Christmases past, present and future are potentially rebirthing processes of indifference that reconnect us to the beginner’s mind of an infant. The mirror of our own personal nativity is the Christmas miracle that bears witness and adoration to the mutual meekness and indifference radiating from the Christ child. The nativity rekindles awareness of our core divinity swaddled in humanity, devoid of accessories and gadgets that keep us wanting more to life.
Choruses that raise their voices and lift hearts sing hallelujah to the inherent value of our own inner child that no longer needs to prove self-worth in order to be lovable. The offspring of our lives and ultimate gift to others is not showmanship, but rather vitality. This neon light of flashing energy is reminiscent of the inherent dignity we all possess. Dignity becomes realized as the value of our existence and vitality in every fleeting moment of life. The image of the Charlie Brown tree captures the steadiness, stillness and center of indifference which supports peace on earth and goodwill towards all.
On October 7, CNN’s headline read: My right to death with dignity at 29. My inbox was flooded with emails regarding the heart-wrenching story of Brittany Maynard, diagnosed with a brain tumor last year shortly after her marriage. Following a craniotomy to remove the tumor and pain-staking research to determine her prognosis and options, she left California to establish residency in Oregon in order to access medical aid in dying. She now possesses a lethal pill that empowers her choice to live or die. She has chosen death with dignity and rightly believes others need this essential weapon to use in self-defense of dignity.
When did death with dignity come to mean physician-assisted suicide or aid in dying? This was signed into law and brought into public consciousness by the state of Oregon in 1997. Having passed the Death with Dignity Act, Oregon residents with terminal illness have the option of being prescribed a lethal pill. Can death with dignity still occur through other means? Is there something undignified about a terminally ill patient choosing not to take this pill? How much confusion is inherent within current statutes across the country regarding end-of-life? As a physician, I am legally required to initiate CPR on patients who lack Do Not Resuscitate orders. Morally, I cringe at the cracking sound of a frail patient’s ribs while preforming chest compressions.
My upcoming book, WISHES TO DIE FOR, addresses the issue of death with dignity from many aspects of personal choice. I gravitate to the prospect of dying from infection over taking a lethal pill when life becomes insufferable. Does selecting to die from natural causes diminish dignity? Are we being sold the idea that dignity is contained in a magic pill? Death with dignity is in the eyes of the beholder. Having compassion for others allows for individual choice and respects human rights. Dignity arises from the certainty of being right regarding personal choice, but becomes degraded when strictly peddled as medication.
Advocates of physician-assisted suicide continue to struggle with the proper terminology necessary to brand this controversial measure as palatable. These advocates seem to have taken sole custody of the word dignity while making it appear to be elective and selective rather than inherent and inclusive. To reclaim dignity for myself and others who prefer not to equate dignity with ingesting a pill, might sensitivity be used to rename the Death with Dignity Act as the Death with Compassion Act? I believe we all agree that compassion is paramount to providing care at the end of life. Nevertheless, supporting individual choice cannot come at the sacrifice of dignity being reduced to the size of a pill.
September is National Yoga Month. I live the wonder of yoga both personally and professionally each day. While September usually represents the beginning of a new school year, yoga offers students a new curriculum for life. Its intimate learning process involves unwinding tension in the body. Each pose becomes a private lesson in living and breathing, diagnosing and healing, acknowledging and letting go. I am not a yoga instructor; however, I find myself reminding patients to slow their breathing, breathe into their pain and use breath to become more conscious of life.
When breathing is constricted, life can become shortened. As breathing expands, life becomes fuller. Many patients present to the Emergency Department with difficulty breathing; experiencing a near drowning, life and death situation. Many times their lungs are fine, yet patients feel a virtual life vest squeezing them as they insist, “It’s not anxiety doctor; order a chest x-ray. Let’s stop talking and do something!” Unfortunately, people need to be at whit’s end before becoming willing to engage in serious conversation about breathing fully, living consciously and taking measures to allow life to end peacefully.
Personal empowerment and security is realized in the ability to breathe, both prospectively and retrospectively. Prospectively, my intention to practice yoga was to strengthen my back shortly after the terrorist attack on 9/11. Retrospectively, I became aware that yoga cultivates personal security. Coincidences in life are conscious and unconscious. Similar to breathing, the mind-body connection occurs unconsciously. Consciously, yoga allows me to be less concerned about situations outside myself and out of my control; creating awareness around what I can do and when to let go. Finding solace allows for smooth transition. The ultimate yoga pose is the embodiment of the corpse pose.
Yoga students realize the difficulties resulting from doing nothing; becoming less human and more spiritual. The disciplined practice of yoga is a microcosm of me and my shadow respecting life and death through Namaste. Namaste honors partnership. One of its depictions states, When you are in the place in you and I am in this place in me, we are one. This mind-body connection or spirit-shadow oneness occurs in the valley of the shadow of death; abiding in nothingness. Yoga provides an essential union between nothingness and peace. Peace is attained when hands are prayerfully folded over the heart-center. The sequence leading up to that moment and ultimately the end of life itself, culminates in one final expiration of fulfillment.
And tongues as of fire appeared to them, distributed among them, and rested. ACTS 2:3
Fr. Pius Sammut’s account in The Meaning of Pentecost traces this event’s origin to the concept of Salvation. As in the first chapters of Genesis, God presents a wonderful plan for personal fulfillment that culminates in people defiling his plan. People built the Tower of Babel and conceived of a universe in which they could reach heaven without the presence of God. Why should I be dependent upon someone else? I must decide for myself. I know better. I am my own god to myself. I know what is right and what is bad. A similar type of sentiment might prompt the creation of personal healthcare directives. In contrast to Babel, where chaos and confusion exists, Pentecost promotes unification. The divine Spirit of Pentecostmight ignite a discussion of universal healthcare directives.
Pentecost could inspire communion with death and lead to salvation through the consensus of a universal healthcare directive. We gather at dying patients’ bedsides. We meet with attorneys. We avoid so-called Death Panels and seek out Death Cafes. We speak in tongues about the right to live or die, but often become frightened at the uncertainty that surrounds our own death. Do healthcare directives enlist God’s plan for personal fulfillment or defile of His plan? Do we let nature take its course or attempt to turn back the hands of time?
Through various attempts at making sense of healthcare directives, my Spirit has settled upon the notion of universal healthcare directives being incumbent upon salvation. We need to be able to speak to one another and love one another within a universal plan directed towards personal fulfillment. A universal healthcare directive would include the end-of life conversation within the circle of life and its seasons; recognizing a time to be born, to live, to survive and to die. Respectively, a universal healthcare directive would provide “galaxies” of prenatal care, preventive care, advance care, palliative and omega care (previously described) to each season.
MedicalXpress released a recent survey titled, Doctors reluctant to discuss end-of-life care with heart failure patient. The survey comprised ninety-five physician providers from the Mayo Clinic system. Of these, only twelve percent of the providers discussed end-of-life care annually, as is recommended by the American Heart Association. Thirty percent expressed discomfort with these conversations; others thought patients were not ready or did not wish to sabotage existing hope. However, the article mentions that there is no evidence that discussing end-of-life issues destroys hope. Ninety-five percent of these providers had referred some patients to palliative care during the previous year. A universal healthcare directive would have 100 percent of providers refer 100 percent of patients to palliative care during the following year; provided there is concern for patients’ salvation.
My formation in the Catholic Church reminds me to be more Christ-like in my thoughts and actions. Easter reminds the faithful that life potentiates rebirth. As the world revolves, we continually move from a state of darkness to light; death to dawn, suffering to awareness. As I attend to most people who assume the role of being Christ-like when they suffer and die, I am reminded that prior to His passion and death there was a pivotal moment of enlightenment known as the Transfiguration:
“Jesus took Peter, John, and James and went up a mountain to pray. While he was praying his face changed in appearance and his clothing became dazzling white. And behold, two men were conversing with him, Moses and Elijah, who appeared in glory and spoke of his exodus that he was going to accomplish in Jerusalem. Peter and his companions had been overcome by sleep, but becoming fully awake, they saw his glory.
“As they were about to part from him, Peter said to Jesus, “Master, it is good that we are here . . . While he was still speaking, a cloud came and cast a shadow over them . . . Then from the cloud came a voice that said, “This is my chosen Son; listen to him.” After the voice had spoken, Jesus was found alone. They fell silent and did not at that time tell anyone what they had seen”. (Luke 9:28b-36)
The Transfiguration of Christ is considered the culminating moment of his public life. It was a glorious moment when His divinity shined through His humanity. Similar to His birth, Jesus is once again seen as the connection between heaven and earth. Transfiguration is defined as a complete change of form or appearance into a more beautiful or spiritual state; to be chosen. By assuming the likeness of Christ, I believe each of us is chosen to die through a spiritual light.
One of the blessings that patients experience when evaluated by an Emergency Medicine physician is that a new pair of eyes can bring clarity to challenging medical dilemmas. As clouds can cast shadows over patients, I am often provided insight into patient’s transfiguration. I am also cautiously silent when others fail to see patients in their spiritual light. Becoming fully awake to a patient’s transfiguration potentially lessens suffering, promoting dignity through Omega care.