death – Brimmings: up from the well

Live Longer Now

It’s funny how your mind takes vast jumps, transcending time and space, hurling you into the past or thrusting you into the future. It’s happening to me now.

I remember sitting in my sixth grade class in Florida, fascinated with my teacher’s story of Ponce de Leon’s search for the fountain of youth, motivating him to travel to a new place, which he called Florida.

I think we’re all Ponce de Leons in quest of perpetual youth. We fear ending, the withering of our youth with its exuberance and beauty; the diminishing of resolve motivated by idealism, born of innocence; the advent of entropy and the descent into morbidities presaging that eternal sleep.

We evade our mortality in many guises, obsessing about film icons who seem to have the best of good looks and agelessness.

Advertisers grow rich, pedaling snake oils to mummify us from time’s erosion.

Religion offers consolation; materialism, avoidance; power, the illusion of mastery.

Mortality is the underlying cadence of the arts, arresting time’s flow in capturing the moment’s essence. Think Keats’ Endymion: “A Thing of beauty is a joy forever/Its loveliness increases;/it will never pass into nothingness….”

Medical science isn’t any less pervaded by its own Ponce de Leon quests into unlocking the mysteries of aging, harnessing our genetic codes, refining the regimens of diet and exercise.

A good number of scientists are busy at work, confident that they’ll ultimately win the day. There is Silicon Valley’s California life Company (Calico) for example, determined and well-funded, zealously hiring the foremost scientists on what it deems a moral mission to vastly beat back aging and pre-empt physical demise.

And there are other start-ups, too, like Venter with its ambitious plan to augment Calico’s efforts by creating a gargantuan database of one million human genomes by 2020.

Unfortunately, the landscape of new technologies is littered with bad case scenarios of Frankenstein prototypes unleashing their new horrors on humanity.

I’ve been reading this wonderful book, The Science of Enlightenment by Shinzen Young, an immensely learned Buddhist monk who has made it his mission to reconcile the best of Asian mindfulness practice with contemporary neuroscience.

I happened to come across this passage that set this present blog in motion on how we needn’t concern ourselves with whether science succeeds in its endeavors of extending longevity. We can have it now:

Now imagine that you will live just a normal number of years, but that your experience of each moment will be twice as full as it currently is; that is, the scale at which you live each moment will be doubled. If you only lived each moment twice as fully as the ordinary person lives it, that would be the equivalent of one hundred twenty years of richesse. Not a bad deal.

Hey, I’ll buy into that. I’m 76 and well aware of the math underpinning insurance actuaries. I’m lucky to have gotten this far, and with reasonable health, but it wouldn’t have mattered to me overly if my demise had been at 60.

I’ve lived my life up to the brim with world travel, including third world countries, conversing and making friends; gone from a Philly street urchin, raised by an alcoholic father, to a professor of English, privileged to share the beauty and wisdom of literature with several thousand students who’ve enriched my life and, I trust, theirs.

I’ve filled my life with passions that have anchored my happiness–a love for reading, nature, languages and writing.

I wake each day, plotting new ventures. As the remarkable Hellen Keller wonderfully put it, “Life is either a great adventure or nothing.”

Not least, there’s been Karen, who entered my life some twenty-five years ago, balancing my introversion with her openness and steady optimism, igniting new vistas with her refusal to foreclose on possibility and stunning ability to rebound from life’s vicissitudes.

Hopefully, the best part of all of this transcends Self in its yield of an encompassing empathy that’s taught me how connected we are to each other and the absolute that we love one another.

For Shinzen Young, longevity is best measured experientially, not chronologically, when we live mindfully in the present. “Meditation is the key to this kind of non-mythical life extension,” he writes. “By developing an extraordinary degree of focus and presence, it allows you to live your life two or three hundred percent ‘bigger.'”

I couldn’t agree more.
–rj

Being Mortal

I’ve just finished reading Being Mortal: What Matters in the End by Dr. Atul Gawande.

I had read his previous Complications about life as a surgeon several years ago, greatly impressed.

Both books have been highly praised, with the present book listed by the New York Times as among must reads of 2014.

As a surgeon at Massachusetts General Hospital, Gawande knows what he’s writing about.

And he writes well, often movingly, in layman’s language, of death scenarios with their accompanying challenges that need to be individualized, since we’re all different.

I suspect many readers will opt to avoid a seemingly morbid subject, but that’s a mistake, for mortality knows no exceptions and our best approach is one that, through knowledge, provides us with options.

And Gawande, a writer for the prestigious New Yorker as well as a physician, delivers–deftly, compassionately, and always with eloquence, on a difficult subject.

Moreover, his book preeminently addresses the medical community, often committed to treatment paradigms that work against the patient’s welfare.

Physicians are trained to see themselves as enhancers of health and survival. They are not taught how to handle lingering illness devoid of remedy:

…within a few years, when I came to experience surgical training and practice, I encountered patients forced to confront the realities of decline and mortality, and it did not take long to realize how unready I was to help them (3).

If your problem is fixable, we know just what to do. But if it’s not? The fact that we have had no adequate answers to this question is troubling and has caused callousness, inhumanity, and extraordinary suffering (8).

What’s the point, anyway, of continuing chemotherapy, radiation, and surgery in terminal cases when such methodologies may involve great risk and, often, increase duress?

When, in short, should doctors, not just patients, let go?

Patients cling to hope and doctors knowingly feed into this, when frequently no regimen can procure that miracle of restoring health and dignity.

Or as Gawande vividly makes clear in his allusion to Tolstoy’s powerful tale, The Death of Ivan Ilyitch:

What tormented Ivan Ilyitch most was the deception, the lie, which for some reason they all accepted, that he was not dying but was simply ill, and he only need keep quiet and undergo a treatment and then something very good would result (2).

The ultimate challenge for physicians is to accept the restraints of biology and assist their patients to come to terms when that moment arrives

Otherwise, they can inflict considerable, even barbaric, suffering.

Doctors need to be patient-centered, addressing the patient’s best interests, and sometimes the greatest kindness entails being candid..

Ultimately, it’s about providing patients with options that preserve dignity, lessen suffering, and are in accord with the patient’s priorities.

We’ve made some progress in the now universal acceptance of Advanced Directives, though initially contested. But what about options for the terminal patient, still conscious, who lingers, often in great pain, and with perhaps even greater to come?

Gawande says that there are two dominating physician protocols: the one patronizing (this is what you should do); the other, informative (here are your scenarios).

Doctors do better when they ask the right questions of their patients in such contexts:

Whenever serious sickness or injury strikes and your body breaks down, the vital questions are the same: What is your understanding of the situation and its potential outcomes? What are your fears and what are your hopes? What are the trade-offs you are willing to make or not willing to make? And what is the course of action that best serves this understanding? (259)

Palliative care, for example, may well be a better option to further surgery, chemotherapy and radiation when the outcome may make matters worse.

On the other hand, indulging patient fantasy may invoke “a prolonged and terrible death” (4).

Gawande carries out what he advocates. For me, his account of his father’s lingering passage into mortality is deeply moving, which I think many of us can identify with in our own wrestlings with the demise of those we love.

In addition to all of you, I wish every medical practitioner would read this book.

Death isn’t an enemy, but the natural order of things.

How much better it would be in our final moments to have someone like Gawande attending–a physician, with compassion, listening and helping us discern those best options that enhance our dignity and lessen our suffering.

–rj

Intimations of Mortality: Keats revisited

I have always been fond of the poet, John Keats. Maybe it’s because he seems to have been down on his luck so early in life and I just happen to be drawn to underdogs. When he was just eight, he lost his father, who died falling from a horse. At fourteen, his mother succumbed to TB, a disease that would prey upon the family, taking his brother, Tom, at nineteen and himself at barely twenty-five. Meanwhile, lawyers consumed the family inheritance.

Keats always had a premonition of an early death, not surprising given the family history, but he didn’t know he was already ailing with TB when he became engaged to the girl next door, the coquettish Fanny Brawne in the fall of 1818.

The following year saw Keats penning in a six week period the masterpieces for which he is now famous, poems like “Ode to a Nightingale,” “Ode to Melancholy,” “Ode to a Grecian Urn,” “Ode to Psyche,” and “La Belle Dame Sans Merci.”

On February 3, 1820, he coughed up blood in his bedroom and with his typical courage, exclaimed: “I cannot be deceived in that color; that drop of blood is my death warrant. I must die.”

He would travel to Italy in a last desperate attempt to recover his health, only to die a few weeks later, attended by a lone friend. Today he lies in Rome’s Protestant Cemetery. Engraved on his tombstone is Keats’ chosen epitaph: “Here lies one whose name was writ in water.”

I have always been attentive to Keats, visiting his last London Home, Wentworth Place, in lovely Hampton Heath, and his last abode abroad, a small apartment in Rome adjacent to the Spanish Steps, Rome’s gathering place for throngs of young people from across the globe, presumably oblivious in the “mackerel crowded seas” (Yeats) to the drama enacted next door eclipsed by time. I have also been to the cemetery, moved and reflecting on what might have been a different outcome with a better shuffling of the cards of fate.

He had aimed to write the best poetry of which he was capable and though dying so young, achieved a poetry the world still marvels at. No poet, not even Shakespeare, Milton, or Wordsworth achieved such mastery at so young an age, laboring against illness, family misfortune, financial duress, rejection by the critics, and the anguish of loving a flirtatious Fanny, who often provoked his jealousy.

Of all the Romantics, he strikes me as the most poignant, ever aware of life’s brevity, or how temporality colors all, testing the significance of human assertion itself. Paradox always characterizes his poetry and centers in the conflict of dream vs. reality. Unlike many Romantics, Keats ultimately opts for truth in the interplay of mind and feeling.

I have been thinking a lot about him lately in conjunction with the cancer hoops I’ve had to jump through these pastt several months. I had gone to an osteopath seeking relief for my back pain only to be told xrays showed a lump adjacent to the left clavicle, which might be cancerous. A subsequent CT scan, though it showed no malignancy, revealed a large thyroid nodule, and I was again cautioned it might be cancer. They found me a surgeon and in the meantime I had an ultrasound guided fine needle aspiration biopsy, which indicated another, smaller nodule on the left side of the thyroid. The pathology report came back negative.

By then I met with my surgeon, who surprised me in light of the biopsy: “I can’t guarantee you don’t have cancer. FNAs have false negatives up to 20% of the time.”

While waiting for surgery five days away, I visited my dermatologist to check on a knee sore, which turned out inconsequential, Alas, however, she found a black mole that might be melanoma, the most aggressive of cancers. And so I had to go into surgery facing the double whammy of two cancers at separate sites, metastasis a distinct possibility.

The surgery went well. The surgeon didn’t find cancer, so only a partial thyroidectomy was done, allowing me to perhaps avoid medication. But I still hadn’t gotten the lab results on that black mole. I had to actually call to get the report. It was a precursor dysplasia nevus, which can turn into melanoma if not removed. Even though benign, having dysplasia nevi increases your chances of getting melanoma, so it means constant vigil to catch early changes.

And so now you know why my thoughts have been so filled with Keats, though in this medically sophisticated age I’ve come upon some luck this dear poet was denied. Living with premonition of his own demise, Keats wrote what may be my favorite poem, and I mean of any poet,

When I have fears that I may ease to be
Before my pen has gleaned my teeming brain,
Before high-pilèd books, in charactery,
Hold like rich garners the full ripened grain;
When I behold, upon the night’s starred face,
Huge cloudy symbols of a high romance,
And think that I may never live to trace
Their shadows with the magic hand of chance;
And when I feel, fair creature of an hour,
That I shall never look upon thee more,
Never have relish in the faery power
Of unreflecting love—then on the shore
Of the wide world I stand alone, and think
Till love and fame to nothingness do sink.

If you look at this poem carefully, you’ll find it fascinating in its astute organization; for example, the poem actually consists of one sentence, or subordinate clauses coalescing into a main clause at poem end. In turn, this lends an accumulative buttressing of the persona’s earlier mention of his “piled up hopes.”.So many hopes, teeming high, but cut off by mortality.

The poem’s structure also features an antithesis between thinking and feeling in its three quatrains prior to the closing couplet in this Shakespearian sonnet.

Strikingly in consort with its theme, each quatrain moves us closer to the reality of death, with a progressive abstraction in the imagery with each succeeding quatrain:

Increasing abstraction:

rich garners

cloudy symbols

faery power

nothingness

These quatrains also unleash inexorable transitory strictures of foreclosure, feeding into the “nothingness” of the closing couplet in which death renders all human dreams, whether of love or fame, insignificant.

Increasing transitoriness:

autumn

one night

one hour

The poem’s imagery is likewise supportive of the theme, with an imagery cluster featuring darkness, shadows and clouds,

For the poet, death represents closure on love and artistry and fame. I remember reading one of Keats’s letters in which he called death “the great divorcer.”

The truth is that ultimately we all get our ticket punched; but for Keats, he was so young, talented, and in love. Sometimes life can be cruelly unfair. Nonetheless, with the quiet courage that always characterized him, he accepted his fate.

There are lessons here for all of us: to pile up the nows, knowing the temporality that governs us all; to live quietly and simply, centered in the right values; to discern those issues that matter; above all, to love amply those around us.

–rj

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