Category Archives: the process of death

A new meaning to New Year, New Me

As I was browsing Netflix in search of a new show – an extremely terrible idea with finals’ season approaching – a trailer for a new Netflix original series began to play. After being in this class for nearly a full semester, the first lines of the preview immediately caught my attention:

“Your body is not who you are. You shed it like snake sheds its skin.”

So, against my better judgement, I watched the first episode of Altered Carbon. (Don’t worry, I will not spoil anything). The show centers on the character Takeshi Kovacs who has just awoken in a new body after 250 years ‘on ice.’ While this is extraordinary to me, and I am assuming to you readers as well, for him and everyone else in his society this body replacement is perfectly normal. In this sci-fi universe, set about 300 years into the future, everyone gets a “stack” implanted at the base of their skull when they turn one. Each person’s stack stores and codes their consciousness. When they die their stack can be implanted into a new body, or “sleeve,” and they can continue living, but only if they can afford it. Sleeves are extremely limited. Thus far, it has not been made explicitly clear, but these sleeves seem to be the bodies of prisoners. Regardless, no one truly dies unless their stack is destroyed. It is technology that permits brain transplantation and with slightly less mess than previously imagined.

This kind of innovation would completely change the human perception of life and death. Humans would be able to outlive their own bodies. It would put immortality within reach. If someone had the means, they could go on living indefinitely. But brain transplantation would also create huge ethical dilemmas. We would have to determine if it is even morally sound to inhabit a new body. We would be forced to decide whose bodies would be for sale. Would we, like this show, use prisoners? Or, like Get Out, kidnap Black people? Or use losers in wars? Or would we, by then, have the technology to upload people into robots? We would also have to decide who could receive a new body, at what point in their lives, and how many times they could be transplanted. It would change everything.

Do you think our society will ever reach this point? Do you think brain transplantation is ethical? What are your ideas on whose bodies should/would be used? Would you ever want to be put into a new body?

Cats, Computers, or Doctors: Who’s the best at predicting death?

In society, there are many omens associated with impending death. Some may say they had a dream about death while others may associate death with the portrayal of the grim reaper. In the case of Steere House nursing home in Rhode Island, impending death is in the form of a black and white cat named Oscar. He was adopted as a kitten by the medical staff and his sharp acumen has never led him astray. As soon as the doctors see Oscar curl up next to a patient, they inform families to come visit their loved one for one last time. Out of the 50 patients the cat has cuddled up next to, all 50 have died within a short span of time after their visit with Oscar.

This story was first published in 2007 in the New England Journal of Medicine and has stuck with oncologist, Dr. Mukherjee, since. While he may not have the ability to smell the air of death like Oscar, his medical knowledge has helped him predict the viability of a patient’s condition. However, what happens if your predictions are wrong?

Oscar, the cat that can sense death in Steere House nursing home in Rhode Island

Oscar, the cat that can sense death in Steere House nursing home in Rhode Island

In the case of a 32-year-old plumber (patient X) suffering from esophageal cancer, treatments and surgery left this patient with a good prognosis. While there were no signs of tumor left in his body after surgery, Dr. Mukherjee prudently approached the topic of relapse. It was unlikely that the cancer would return; however, the small chance of a relapse still remained. Dr. Mukherjee believed that it might be better for X to have a conversation with his family about this possibility and plans for the future. X was reluctant to follow through with this because he had just defeated cancer and what was the point in worrying about a distant (and unlikely) future anyways? Two months after X was released from the hospital, he relapsed and only the highest doses of painkilling drugs that left him spending his last living weeks in a coma-like state could treat it. His family was devastated and accused the doctor of misleading them about his diagnosis.

Armed with their medical knowledge and results from medical tests, doctors still have a difficult time predicting the death of their patients. For some physicians, they are able to accurately predict how much longer their patients have to live, others tend to underestimate this time, or even overestimate it. This variability makes it difficult to find “the sweet spot of palliative care.” However, what if a computer with an algorithm could predict how long you have left to live?

In 2016, a Stanford medical team and an engineer developed an algorithm that could be taught to identify patients that had 3 to 12 months to live. This was the ideal window of time for doctors to treat patients in the manner that was most effective and appropriate for the patient. Any time less than three months was not enough time to prepare for death and more than twelve months could place an unnecessary strain on the already limited resources in hospitals. As the algorithm underwent a deep learning process and absorbed patient data from more than 100,000 cases, the results were startlingly accurate. Computers using this algorithm were able to correctly predict which patients were going to die within 3 to 12 months nine out of ten times.

However, what is it that this algorithm has that doctors don’t? They both have access to medical information such as a patient’s diagnosis, how many medical tests are ordered, procedures conducted, prescriptions ordered, and the duration of stay in the hospital. Yet, this algorithm, that was recently developed, was better at predicting which patients had 3 to 12 months to live than physicians. It turned out the analyses differed. In the case of a patient diagnosed with bladder and prostate cancer, he was assigned a high probability of 0.946 of impending death. While doctors did not consider the patient’s MRI scan of his spinal cord as a sign of impending death, the algorithm recognized this as a predictor and was able to accurately predict the amount of life left in the patient.

The development of this “dying algorithm” is a huge step in technological advancement. From a medical perspective, it allows physicians to administer palliative care. From a patient perspective, it gives them ample time to discuss goals and futures with their loved ones. However, this also opens up a different side to medicine. What happens when a computer with a dying algorithm is able to understand death better than most humans, including your doctor? Would this result in a decrease in trust in physicians and turn into machine vs. doctor phenomenon? While this may be an issue in the near future, there is much room for growth in both the algorithm and physicians in predicting impending death. So how would you like to be told when you’re going to die? Would you rather be told by a fluffy black and white cat that will cuddle up next to you, an analytical computer spewing algorithmic probabilities, or a human M.D.?

 

When Expectations Do Not Match Reality

Over the course of this class we have read and seen many examples of how different people relate to death. That being said, there has always been a sort of unspoken rule that discussing death should always be done in a respectful and mature way. What happens when that is completely turned on its head?

Well adorned casket set up for viewing

Casket, Museum of Funeral Customs, Springfield, Illinois, 2006 by Robert Lawton

The musical Fun Home has a lot of layers to discuss. It follows the true life story of Alison Bechdel, an American cartoonist who grew up in her father’s funeral home. The musical goes on to follow Alison discovering her sexuality, dealing with her closeted gay father’s infidelity to her mother, and ultimately her father’s apparent suicide. There is a lot to unpack there. However, one of the most striking moments for me, the moment that really turns all expectations on its head, is the song “Come to The Fun Home.” This song is the imaginary advertisement child age Alison and her siblings try to make for their family’s funeral home. 

Photo by mohamed_hassan

When you witness children running across stage, singing a happy and childlike melody, but having the lyrics “You’ve got to bury your mama / But you don’t know where to go” or “Our caskets (ooo) / Are satin-lined (ooo)” you cannot help but laugh. This humor comes from the inherent disconnect between children playing around and a song about funeral home practices. The catchy little rhymes continue as they mention that the Bechdel Funeral Home has folding chairs, smelling salts, ample parking, and more. It goes so drastically against our perceptions of a funeral home and those who work there that it is hard to even frame them in the same mental image. The fact is we think of funeral homes as somber locations and playing children are practically the symbol of life.

Now why else is this so shocking? For one our western society has the tendency to try to hide or diminish death from young children, not let them play sword fight with aneurysm hooks. This openness with death with those so young immediately sets off alarm bells. Also there is a lack of reverence to death within the lyrics, the staging (the kids playing on a casket), and the melody that completely disorients our normal perception of the processes and rituals surrounding death. All of this leaves the audience hysterically stunned.  What I believe the general public should take from this moment within the play Fun Home is the reminder that death is not inherently somber. Our relationship with death is entirely a societal convention and while it is not necessarily bad to be conditioned in such a way, it is important to recognize that it is there.

Watching Fun Home was one of the most powerful theatre experiences I’ve had in recent years and I highly recommend either seeing the show, reading the graphic novel it was based on, or listening to the soundtrack if anyone is interested. Keep your eye out for this particular scene and see if it challenges how you view death.

Do we really want to live forever?

Society has always been an obsession with immortality, with living forever and never having to fear death. This fascination with immortality can be found throughout legends and stories, from the Greek gods, to books such as Tuck Everlasting and movies like Peter Pan. Living forever seems like the perfect storybook ending where we can all live “happily ever after”.

Recently, immortality has come into the spotlight even outside the world of fiction with research by Dr. Julian Chen on DNA. While the normal cell may shrink and loose some of its DNA as the years go on, this study has potentially found a way to stop DNA shrinkage that leads to cell and organism death. The potential is in telomeres, which are protective capping structures on DNA. These caps act like the plastic at the end of shoelaces: without them, the strand would become frayed and we would not be able to tie our shoes anymore. In the cell, the loss of telomeres leads to DNA unraveling and an inability of the cell to divide, both of which lead to cell death, weakness, illness, organ failure and organism death.

This shrinking of telomeres is due to time, cellular divisions, and the telomere regulatory enzyme called telomerase. These enzymes keep cells from aging too fast by adding telomeres back onto aging DNA and adding lost DNA nucleotides back into place in the DNA strand. Dr. Chen hopes to target the telomerase, accelerating its activity to slow down the degradation of DNA and the resulting cell death. If he were to be successful, he would be creating immortal cells that can continuously divide and support life.

This study shows that the immortality may not just be found not in stories or myths or legends, but through science and in our own bodies. Yet as these scientific advancements take place, we must ask ourselves: is science going too far? Do we really want to live forever?

My original response to this was an optimistic yes, as I thought of all the good we could do. Without death, lives would not taken and no one would have to be separated from their loved ones. But after reading Dr. Chen’s article the potential to create immortal cells, I began to wonder if having immortal bodies would be worse than dying. What would happen with exponentially rising numbers of immortal bodies? How would the world deal with overpopulation, lack of resources, fighting, wars, and more? There is a lot that could go wrong with this model, and the errors would have a presence in society forever.

So while evading death may seem like a fairytale ending, immortality has the potential of leading to many social problems, such as overpopulation and lack of resources, that are currently only solvable by death. Therefore, death may be what is saving us in the end from suffering even though we try to fight it each and every day.

 

 

Sources:

Chen, Y., J.D. Podlevsky, D. Logeswaran and J.J.-L. Chen. A single nucleotide incorporation step limits human telomerase repeat addition activity. EMBO, 2018 DOI: 10.15252/embj.201797953

Arizona State University. “Hidden secret of immortality enzyme telomerase: Can we stay young forever, or even recapture lost youth?.” ScienceDaily. ScienceDaily, 27 February 2018. <www.sciencedaily.com/releases/2018/02/180227142114.htm>.

Death Machine

Right to die groups over the year have tried to portray death as a positive experience. They want to desensitize the general public to death, removing the negative connotations of assisted suicide. Dr. Philip Nitschke is looking to revolutionize the controversial topic of euthanasia with his death machine, the Sarco.

In 1997, Nitschke founded Exit International, a nonprofit that advocates for the legislation of euthanasia. This followed him administering the first legal, lethal, voluntary injection to a terminally ill patient in history. This occurred under the short-lived Australian Rights of Terminally Ill Act, but it shifted his perspective of self-inflicted suicide. Rather than being a concept reserved for the terminally ill, he believed that any rational adult should be allowed to experience a “good” death. Modern medicine can keep individuals alive for far longer than previously possible, leaving people in deteriorating states.

The majority of Exit Internationals members are the elderly, providing them with information on how to die with dignity. What Nitschke is currently striving for is to provide individuals with a death that is more than just “dignified.” He wants the passing into the afterlife to be a euphoric experience. Therefore, the Sarco was designed to have a spaceship-like aesthetic to make it seem as if an individual is “journeying to the great beyond.” This would remove the stigma that was often associated with the doctor’s prior machines. The previous inventions tended to reinforce the macabre stereotype of death, which served to put people off. Rather than dying strapped to a plastic bag, an individual can choose where and when to initiate the procedure.

The main draw behind the Sarco is that in concept it can be transported anywhere. No longer will people be restricted to hospitals to administer the euthanasia, they will have the opportunity to take into account the critical factor of where you die. The process is also painless and provides one of the most soothing feelings before death. The machine euthanizes individuals through hypoxia, where the oxygen level is lowered to the point that a person can still breath easily to receive the intoxicating sensation. The user then subsequently looses consciousness and dies.

The process to utilize the machine is also very personal, limiting outside interventions. A user has to fill out a survey which declares if they are mentally fit to make the decision, and they then receive a 24-hour access code to use at any Sarco machine in the world. When the code is entered at a device, the process commences. It’s an exciting concept, providing individuals with a possible alternative that could make their experience more personal and unique. In the end, it allows individuals the opportunity to achieve what they could consider being a “good” death on their own terms.

References:

https://www.huffingtonpost.com/entry/sarco-death-philip-nitschke_us_5abbb574e4b03e2a5c7853ca

Meet the Elon Musk of Assisted Suicide

 

 

Putting the Fun in Funeral

What describes your life? Is it a camera? A football? Maybe a plane? I have a hard time picking an object that sums up my life, but some people have the perfect idea in mind.

That is where Paa Joe from the Ga tribe in coastal Ghana comes in. Unlike modern Americans, people in Ghana celebrate death and commonly commemorate it with elaborate and unique coffins. The living aim to honor their dead with coffins that represent their legacy. Paa Joe, after almost five decades in the business, now works with his son to handcraft these highly sought after caskets. His son explains that their coffins

“remind people that life continues after death, that when someone dies they will go on in the afterlife, so it is important that they go in style.”

Ghanian families and surrounding community members place much value on showcasing the part that contemporary African art plays life and death.  They strongly believe that the dead must be buried in something that represents the role they played while alive, in order to remember where they come from and what they have left behind as they move into the afterlife. Although these handmade coffins can cost upwards of $15,000, people of the Ga tribe believe that it is more honorable to live in lifelong debt because of the burial ceremony than it is to cut the costs of a proper funeral. In conjunction with the idea that the funeral is the culmination of all life events, it is extremely vital to allocate all resources to executing this ritual in the proper fashion.

I find it very interesting that although the casket appearance is intended to encapsulate someone’s entire life, the people within the casket actually have no say in deciding what that object will be. Family and friends are tasked with the job of determining what they commission Paa Joe to create. What object will a part time fisherman, talented artist, soccer-loving father be placed in?

Reducing a person to the representation of a singular object goes hand in hand with the impersonal nature of the cadaver. The cadaver may symbolize the person and the life they once had, but in itself is bereft of any form of personhood. Memories and stories take the place of the body in terms of remembering who the person was and what they were like. These exquisite coffins are by all means quite impressive, but many could argue that they are unnecessary. After 3-4 days of public display, they are lowered six feet under the ground and are never seen again. Culturally they still uphold values of social order and religion, but physically they play a minimal role in the end of life.

All things considered, would you want to be buried in a fantasy coffin, and if so…what would it be?

For more information and pictures, click here or watch this short clip.

References

https://www.npr.org/templates/story/story.php?storyId=4496430

https://www.theguardian.com/world/2016/nov/24/paa-joe-ghana-fantasy-coffin-artist-casket-funeral

https://www.cnn.com/2016/10/14/africa/gallery/ghana-coffins-mpa/index.html

 

 

 

 

Death of the Northern White Rhino

This week, the last male northern white rhino, Sudan, finally died from age-related complications along with a newly developed infection on the back of his right leg. To prevent the complete death of the species, Sudan had been kept under the protection of armed guards at the Ol Pejeta Conservancy in Kenya. Conservationists expected his death, but regardless, his passing still shocked the world.

Though most news outlets have reported that Sudan died at the age of 45, most chose to omit the fact that he was euthanized. Would it be that the news agencies are trying to steer the public perception of Sudan’s death away from the conceptual “bad” death? The problem with this is that according to Michael C. Kearl, Sudan died according to the predetermined scripture. By definition, his passing should be considered good as it was an “on time” and those closest to him had felt the warning of his death. This serves to bring up the idea that his putting down might have been left out of major news stories due to the negative stigma associated with human euthanasia. The putting down of animals is something that has garnered near universal support over the past couple of decades, even receiving approval from PETA (People for the Ethical Treatment of Animals). Though Sudan is not considered a human being, the status he had garnered before his death on social media and in the news granted him the title of essentially a celebrity. Therefore, due to the social stigma associated with assisted suicide and euthanasia for human beings, certain news outlets might have chosen to omit this information due to Sudan’s transcendence of status.

The dismay felt by the world is not solely directed at his death but the “death” of the northern white rhino species as a whole. The issue that arises with Sudan’s death is while it should serve as the species’ death warrant, the intervention of medical practices and technologies are complicating the process. Similar to an extent to the case of Terri Schiavo, developing technologies are making individuals question whether this truly means the end for the species. The Schindler’s experienced the same confusion when doctors provided information on unproven therapies and treatments that could restore brain function to their daughter. What the general public is currently dealing with is the initiative by scientists to attempt to take sex cells harvested from northern white rhinos and use them through the method of IVF (In Vitro Fertilization) to impregnate southern white rhino surrogates. Though the technology is experimental, it leaves the general public in a state of uncertainty similar to that of Terri Schiavo’s parents, unsure of whether to mourn the death of the species or not.

References:

https://news.nationalgeographic.com/2018/03/northern-white-rhino-male-sudan-death-extinction-spd/

http://www.bbc.com/news/world-africa-43468066

https://www.independent.co.uk/life-style/health-and-families/features/euthanasia-for-animals-what-can-it-teach-us-about-assisted-suicide-in-humans-10405840.html

 

Making the Most of Life

We often talk about what it means to “truly live” or even more simply what it means to be considered “living.” This idea was one of the main points of the Terri Schiavo case and this idea came back to me in the form of a conversation.

A few weeks back, I was talking to one of my best friends about a book she had recently read called When Breath Becomes Air. The book is an autobiography written by Paul Kalanithi. Kalanithi was an outstanding medical student at Stanford who was in the residency stage in his path to becoming a neurosurgeon and all was well in his life. Then one day, his life came crashing down as he was diagnosed with terminal Stage 4 lung cancer. My friend explained to me that Kalanithi wrote the book to not only tell his story but more importantly to discuss how to think of and approach life when diagnosed as terminally ill. Kalanithi talked about how he truly “lived”when he realized he was dying. Although I haven’t read the book (yet), I did a good amount of research and surfing behind Paul’s story to get a better idea of his vision of life.

As the news of the death of Stephen Hawking shook the world, I came across an article on the web, and a particular line caught my attention. “Those who live in the shadow of death often live the most” was the opening line of one of the paragraphs. Although the article was about Stephen Hawking and his life, I immediately thought back to the conversation with my friend about Paul Kalanithi. This is the idea that he so very well embodied in his memoir, and I would like to share a few thoughts on how he did so.

It is obviously a far stretch to claim Paul took his situation “in stride”, but the way he talked about how to approach death with grace makes the reader reconsider what it means to be fully alive. Paul often talked about his experiences in residency, and repeatedly brought up that he didn’t want to be a doctor to “help save lives” as the cliché goes. For Paul, the biggest goal was to help people understand death and illness. Helping save someone’s life wasn’t worth it to Paul if it meant that patient was now bound to a life that he would not find worth living (being severely handicapped, for example). This was a bigger failure to Paul than the patient dying. We often set an ultimatum for those that are ill. We think they must be saved at all costs because in our minds; death is the worst possible scenario.

Kalanithi claims life isn’t about avoiding suffering, because everyone will die. There is not point in worrying about death, because as long as you aren’t dead, you are still living. I will definitely have a much better idea about Paul’s message when I get around to reading the book soon, but the article that I came across reminded me of the conversation with my friend and even further, the Terri Schiavo case. There is of course no one right way to approach death. But Kalanithi’s message is certainly one that can potentially alleviate stress and make this adventure that we call life a little more pleasant.

References:

When Breath Becomes Air by Paul Kalanithi

The Death of a Dog

Old black lab whose fur is beginning to grey

“Wise old man” by Shaun Hopkinson is licensed under CC by 2.0

In our society, it is common practice to euthanize dogs in old age either with or without chronic medical conditions. However, physician assisted suicide for human beings is controversial and only legal in some parts of the United States. Now, I understand that the comparison between the death of a dog and the death of a human may appear insensitive or tactless, but I think it is one that deserves attention. I frequently hear dog owners, myself included, say that they love their dog as if they were their own child. If this love is so intense and comparable to the love we give other humans, why do we, as a society, condone and even promote the euthanasia of dogs while we shudder at the idea of euthanizing humans?

Pet owners often decide to put a dog down because they are in apparent pain, or the family believes that they should not suffer any longer. The family makes this decision based on the observed quality of life, but they have no idea of the dog’s wishes. Dogs cannot speak for themselves or express their will, but humans make the decision to end their life for them. It is never an easy decision, but it is one that our society supports.

The euthanasia of humans is a much more divisive topic in our society. In recent years, physician assisted suicide has become legal in some states. The idea is that those with chronic conditions may choose to die with dignity. Yet, many regulations are in place, for example, the patient must request to die at least three times, twice verbally and once written, and the person requesting to die must be able to administer the drugs themselves.

These requirements are not necessary for euthanizing dogs. The consent of the dog is not obligatory, and the fatal concoction is administered by a veterinarian, not the dog. While it may seem silly to expect anything of that nature from a dog, I think in some situations it is also ludicrous to expect it from a chronically ill human. Quadriplegics with a poor quality of life and the desire to die are not eligible for physician assisted suicide despite their request because they would not be able to submit a written request nor administer the drugs themselves.

This post is by no means an extensive analysis of euthanasia nor is it an argument in favor of physician assisted suicide or one against the euthanasia of family pets. I simply found it to be an interesting perspective on the matter. An article from the New York Times, titled The Death of the Doctor’s Dog offers a more detailed account of the moral questions that arise when discussing the euthanasia of any living being.

 

References:

https://www.deathwithdignity.org/learn/death-with-dignity-acts/

https://www.nytimes.com/2018/02/06/well/live/death-dying-doctors-dog-euthanasia.html

Dying in the Age of Social Media

Death is typically a private affair, with those in the US even making a private industry regarding the process of dying. People who are experiencing long and drawn out deaths are often hospitalized or placed into hospice care or into a nursing home. Death is distant for those who are alive, with the dying being handled by professionals. This is the way things have been in modern history in Western society. However, this may be changing. Recently, social media has become more popular than ever, with millions using sites such as Twitter, Instagram, Snapchat, and Youtube. This has created public connections in areas that have always been respected as private, such as death and dying.

The surge of social media usage has not escaped those who find themselves in the process of dying. In fact, some of these people have capitalized on this market and have shared their stories and experiences in a non clinical setting. This has allowed a community to develop within the internet of those who can understand and empathize one another’s experiences. Having someone to talk to who is going through the same thing is perhaps easing the way for individuals who find themselves dying.

This phenomenon has also provided a surge in autopathography, or ill people who are writing their autobiographies, including their documentation of illnesses. The openness of these people who are dying is providing physicians and therapists with valuable information regarding their thoughts and feelings during their last days. While people may be reluctant to share their deepest thoughts with medical professionals, they often find it much easier to share with strangers who know what they’re going through. This can assist these professionals in treating the dying in all aspects of their lives, not just the purely physical symptoms.

The use of social media in death is also allowing families and friends more time and ways to grieve. As their loved ones are immortalized with profiles, blogs, pictures, and videos, they can revisit these things at their leisure and take comfort in knowing that they’re always there. Similarly, it provides distance, because while mementos kept in a home are constant visible reminders of what they’ve lost, having the ability to look at social media kept by loved ones after they’ve past requires the effort and the conscious decision to look at it.

However, this publicization of death has come with a drawback in that the dying are focusing more on publishing their experiences. This has raised concerns that they are possibly withdrawing from friends and family, in favor of virtual friends and robbing the family of the chance to say goodbye. While this is certainly a possibility, after all, death is about the living, not the dead, I think it is selfish to deprive people from access to those who understand the intimate details of their illness. If death is about those left behind, then the least we can do is make dying about those who are actually dying.

http://theconversation.com/how-the-digital-age-has-changed-our-approach-to-death-and-grief-38207