Our Crash Course in Being Mortal

Palliative-care physician Ira Byock sent this note to our chief content officer, Elise Loehnen. We loved it and wanted to share.

COVID-19 has rudely pulled us into a lucid dream in which we’re enrolled in that course on Contemplating Death we never signed up for. Class has already begun, we’re not prepared, and assignments are due. Daunting as the situation is, for those willing to do the coursework, the lessons may be both enlightening and immediately applicable.

For most of us, death is an abstraction. We know it will find us sometime, somewhere, but that’s all we know. In reality, we live every moment of every day just a heartbeat—or a lethal dysrhythmia, or a head-on collision, or a stray gunshot—away from eternity. Although we can acknowledge all this intellectually, dwelling on a random demise seems senseless, so we don’t. Our busy lives blanket us from remembering how proximate death is.

“Daunting as the situation is, for those willing to do the coursework, the lessons may be both enlightening and immediately applicable.”

This semester, COVID-19 has ripped the comforter from our shoulders, leaving us shivering in the cold light of death. Even if we personally survive—and we tell ourselves, “I will make it through”—we will not avoid knowing people who die.

It’s no exaggeration to say that COVID-19 is a plague of biblical proportions. This Passover, our oldest family members rather than our first-born children are most at risk. Instead of marking our doorframes with the blood of lambs, we are taping up thank-you notes for delivery workers who are helping us ward off the Angel of Death.

I’m thankful that we can draw on human experience with previous plagues, twenty-first-century science, and millennia of wisdom traditions in dealing with the current global threat.

Because of my work in palliative care, I’ve been fielding questions from family and friends—all de facto students of this course—about how to deal with the newly heightened prevalence of death surrounding us. I’ve drafted a helpful study guide with key takeaway points.

Assignment one: Stay safe. Acceptance of death is oversold. Dylan Thomas had it right. Why not rage against the dying of the light? After all, we’re all going to be dead a long time. An effective strategy for living fully is to not die prematurely. So stay home, wash your hands, wear masks, and try not to touch your face.

Assignment two: Get your house in order, literally and figuratively. There’s a Passover tradition of using a feather to collect lingering crumbs of leavened bread. My wife and I have begun spring cleaning our closets of decades-old files, receipts, and tchotchkes that no longer have value. We’ve also found old photos and letters that have become priceless and need to be digitally preserved. In the inner rooms of our lives, we’ve finally gotten around to updating the will we created in 1998. I’ve been reaching out to old colleagues and friends to check on them and let them know they’re in my thoughts. If death finds me, I want to be right with the world and, most importantly, right with the people who matter to me.

Assignment three: Face your fears. This is the most difficult assignment by far and requires preparation for the final exam. Human beings are a self-conscious species, aware that, ultimately, none of us gets out of this life alive. It is worth examining what it is about death that we fear. Nonexistence? I’m not so sure. Consider: Is it scary to contemplate where you were before conception? I’ve yet to meet anyone who answered yes to that question. More likely, it is the loss of having been that evokes death anxiety.

When meditation teachers guide students in contemplating nonexistence—staying present without recoiling—death’s menacing face commonly dissolves into sadness. The prospect of endless separation from the people we love occupies the core of what we dread about being dead.

If that’s so, the pathophysiology of COVID-19 seems designed to realize our worst nightmares. Patients who become short of breath with this infection often deteriorate rapidly and do better in the long run if rapidly sedated, intubated, and mechanically ventilated. Twelve to sixteen days or more days of intensive ventilatory support may be needed for people to improve—or to know that they cannot. But the separations are immediate. The few minutes between a clinical decision to intubate someone and sliding a tube through their vocal cords, may be a patient’s and family’s final chance to communicate.

I’ve learned from people of my grandparents’ and parents’ generations who lost lovers, friends, and relatives during WWI and WWII, as well as through all the routine causes of death, that grief is profound and at times unbearable, but that sorrow can be endured. Those who were resilient seemed to accept grief as the cost of love. The familiar lines from Tennyson’s “In Memoriam A.H.H.” are apt: “’Tis better to have loved and lost / Than never to have loved at all.” They taught me that without denying sorrow, it is possible to feel gratitude and joy.

Facing one’s deepest fears can bring new freedom. Culturally, this is a WTF moment, which a coworker’s mother thinks stands for “Well, that’s fantastic!” Unwanted as it is, this crisis provides an opportunity to take stock and reinvest in what matters most. I’d say we’re off to a good start.

“I’ve learned from people of my grandparents’ and parents’ generations who lost lovers, friends, and relatives during WWI and WWII, as well as through all the routine causes of death, that grief is profound and at times unbearable, but that sorrow can be endured.”

There is so much creative energy going into building and maintaining human connections, despite our need for physical distancing. Working in health care, I’ve been impressed and inspired by how quickly we’ve pivoted to using video platforms to perform clinical visits with sensitive conversations and poignant family meetings. For hospital-based clinicians, the most distressing aspect of this pandemic is the need to separate seriously ill patients from their families. While there is no adequate substitute for human touch, family visiting has now gone virtual with surprisingly satisfying results. Families gathered in their homes across states and countries are meeting together in gallery views to visit with sick loved ones. They’re sharing stories of cherished events, gently teasing one another, affectionately forgiving past misdeeds, and honoring and celebrating the person whose life may be coming to a close.

Many nonclinical workplaces also have gone virtual. In addition to project-related meetings, the team I’m part of has initiated informal video lunch socials, as well as occasional after-work happy hours during which we lift glasses of wine or cocktails—my preferred drink these days is a quarantini—while catching up and kibitzing with one another.

“At times it seems we are more connected than ever.”

Homebound families are devising ways of staying connected with relatives. Grandparents are reading to young children over the phone, FaceTime, Skype, or Zoom and figuring out how to use video white boards to play tic-tac-toe, math puzzles, word games, and squiggles. Online communities are flourishing. Faith communities are holding online services. Book clubs and pet groups are meeting by video. Musicians are giving free concerts, and poets, readings. At times it seems we are more connected than ever.

Songwriter Graham Nash once opined: “Life is not perfect; it never will be…you have to open your heart to what the world can show you. Sometimes it’s terrifying and sometimes it’s incredibly beautiful. And I’ll take both, thanks.”

That’s a perspective I hope for us all. May we emerge from this crash course able to look mortal life in the face and declare, “Well, that’s fantastic!”

Ira Byock is a palliative-care physician and the chief medical officer of the Institute for Human Caring. His books include Dying Well and The Best Care Possible.