Lost Art Of Dying | Lydia Dugdale

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Lost Art Of Dying | Lydia Dugdale

September 17, 2020

A faculty conversation with Dr. Lydia Dugdale, a physician and ethicist at Columbia Medical School who’s been on the front lines caring for COVID-19 patients in NYC. Moderated by Kathy Tuan-MacLean. • Please like, share, subscribe to, and review this podcast. Thank you!

Transcript

Welcome to the Veritas Forum. This is the Veritaas Forum Podcast. A place where ideas and beliefs converge.

What I'm really going to be watching is, which one has the resources in their worldview to be tolerant, respectful, and humble toward the people they disagree with? How do we know whether the lives that we're living are meaningful? If energy, light, gravity, and consciousness are a mystery, don't be surprised if you're going to get an element of this involved. Today we have from medical doctor and expert on ethics and medicine, Dr. Lydia Dugdale. As she discusses the Lost Art Of Dying and makes the case that we live better when we are prepared to face our end.

Hosted and facilitated by Kathy Tuan-MacLean, National Faculty Ministry Director at Intervarsity. So Lydia, first maybe the question that's bursting on everyone's mind, what has been your experience with COVID on the front lines? Yeah, so thanks so much for having me, Kathy, and for organizing the Q&A here tonight. It's great to be here with everyone.

So for those of you outside of New York City watching the maps with the red circle slowly expanding and get darker and darker around New York City if you've been following the New York Times, it's looked pretty grim. And it's been busy here for sure. I think it's fair to say that there were several really bad weeks and we have had no shortage of COVID patients, but thankfully there have been fewer than anticipated, so we didn't end up filling all of the beds that were made available to us.

And that's been good news. And our numbers, as all of you know, have been slowing significantly. We've discharged many, many, many patients, which has been good news.

For my own role, I know Kathy, we talked about this. I am a primary care doctor, which means I'm sort of the grown-up version of a pediatrician. And my usual place is in an outpatient clinic when you go for a checkup or something like that, blood pressure check, that's me.

I moved to Columbia last summer and was just getting my own practice up and running in February when COVID hit. And so I switched gears to join with all of my colleagues at Columbia to just join the group of doctors caring for COVID patients in whatever, whatever format I was needed. So I worked in all, I worked in a tent, I worked in the emergency room, I worked in the step-down unit, which is an intermediate level of care between an intensive care unit and the basic medical floor.

So I was really all over wherever they needed me and did that for probably, I guess, four or five weeks. I was kind of circulated around. So it's been nice to be back now in a primary care setting, which is what I know best.

And I'm sort of just as of last week, have returned to my clinical home and kind of getting established now in that again. But the hospitals are very different place than it was. And so I think all of us are trying to figure out what this means going forward.

And then of course, the questions which no one has answers to what happens this summer, what happens in the fall, certainly with the density, the population density of New York City, there's, there's still a lot of fear and anxiety among people in general about what this might mean as we approach flu season again in the fall. Thanks, and thank you for your service. I'm sure it's been quite overwhelming.

One note before I ask you the next question, which is, I'm getting chats from texts from my friends saying chat is not working. So I'm here to tell everyone that the chat has been disabled. So please do you slido.com. Well, like I said, I had the privilege of reading your book.

And boy, as I read this book, which I know you wrote a year or two ago, it felt very prophetic for this day and age we find ourselves in. So how did you get interested in writing about death, isn't it morbid. I suppose so I was very affected as a medical trainee both as a medical student and as a resident.

By really by things that affect many of my colleagues, which is the caring for patients who are sort of lingering in the intensive care unit with all of the technology that modern medicine has to sort of sustain the vital function of a human body. But with all the appearances of a certain death and in fact, the cases that caused the most moral distress really are the patients that that everyone is quite certain are dying, despite our best efforts and yet there's this tension with families often who are so afraid to lose their loved ones and rightfully so. So who then insists on continuing the aggressive interventions and in New York State, at least, if that is a family's wishes by law, we cannot withdraw life support there's no unilateral withdrawing and, but it was these cases and it's not, it's not so much a battle over life support and it's a question of how can we help patients think better about these end of life decisions and how can we help them die better.

So this was a question that I was thinking about a lot throughout my training. What, what would it take to, in a sense, empower patients, how can we put this in the patients hands so that they have the tools and the resources that they need to die better. And of course, you know, as a person of faith this is not simply a question of technology but it's all of the, you know, sort of metaphysical or existential questions if you will these questions of human existence that go along with the desire to hold on to life by holding on to technology.

So this has been kind of rolling around in my consciousness for a long time. And I grew up in a family where talk of death was very common my grandfather was a bomber pilot in World War II and he was a shot down and he had another plane crash and he was shot down and he was a prisoner of course so the man, the man had many lives and he just, he talked very frankly about deaths. All my whole life.

And actually he didn't die until he was 95 even though we weren't sure for the 20 years before he died he was going to die. So he hung on and, but this he was just very frank about this and the need to think about this stuff and get your affairs in order. So I grew up in that sort of an environment and then that combined with the extreme distress caused by these really terrible deaths.

And then this ongoing question of how can we help patients how can we help patients. So it was, it was through these questions that I would do a lot of reading on end of life issues particularly from an ethics standpoint I do medical ethics. And one day I came across a description of the ours more Andy, which was a genre of literature that came out of the late Middle Ages, and was very popular for more than 500 years.

And then the ours more Andy is Latin for the art of dying. And I thought, Oh, this is this is fantastic. These were essentially the genre of literature was essentially handbooks on the preparation for death, addressing both practical matters and these, you know, deeper big questions so called big questions.

I thought, this, this is the kind of tool we need to help our patients, but we live in this very, you know, pluralistic society people have all different viewpoints on these things It couldn't, you know, an effective ours more Andy or an effective art of dying. Couldn't be one that is prescriptive necessarily. At least for it to be picked up by a wide audience.

It has to be something that gets people to ask the questions and wrestle with the big questions. And so, yeah, so that sort of set me on this whole path of scholarship that I've been working on for more than a decade really. So can you tell us more, what do you mean by the art of dying? Yeah, the main thrust of this genre was that in order to die while we have to live well.

And in order to live well, we have to attend to these big questions of what, what does that actually mean? And the ours more Andy was very much a set of practices. So it included all different kinds of things and I should just note that originally it sort of grew out of the Catholic church. And so we had a lot of work that was done in the early 1900s.

And then there were many, many spin-offs and, you know, after the Reformation, there was a product explicitly Protestant version. And by the 1800s, it had been the ours more Andy had come to the US. There were secular versions.

There were Jewish versions. And by the time of the Civil War in the 1860s in the United States, if you were from a good family, if you were brought up well, you attended to the preparation for death by thinking over the course of your life within the context of your community about what it means to die well. So, so, you know, and say maybe our equivalent is a state planning, right, so if you're brought up well, you sort of get your, your financial affairs in order, but, but going way back, it wasn't just getting those sort of pragmatic affairs in order, but it was also attending to the spiritual questions, community questions, questions of the soul, right, these sorts of things.

And so this, this was a part of it. Yeah, so, so it was a genre of literature, there were illustrated versions, text-based versions, they would include everything from protocols for attending to the dying and caring for the dead, all the way through to Q&A, like a catechism, that the community would ask of the dying person, it would include prayers, both for the dying person to prey on his or her own behalf, and also for the community to sort of intercede on behalf of the dying. And one of the big thrusts of the original versions was attention to the five main temptations that at least in the late middle ages, they thought the dying would face, and that would be things like a temptation to in patients, right, let me just die and get this over with, or a temptation to greed, I want to take my earthly possessions with me.

And so they articulate these different temptations, and then articulate a sort of a response or a consolation to those temptations. So this was, this was the core of some of the original versions and like I said, there were so many spin-offs. Thanks for that.

So I was very struck by how maybe the thesis of your book is in order to die well you have to live well, and you have to figure out how to live well. So if you were to describe what it looks like now because that is many of our minds with this pandemic. What would it look like to live well now and in this moment? Yeah so I talk about how if we were to reduce the Rs.

Mauryandi to its most basic level right the lowest common denominator of what we can expect, or what we could hope for and again this would be in the setting of a very pluralistic society where we may not be able to agree on the answers to some of these so-called big questions. But if we were to say the art of dying or living well in order to die well means nothing else, it does mean that I think it requires at least two things. It requires an acknowledgement of human finitude.

So there's no way to die well if you don't even give any thought to the fact that you are mortal. This idea of finitude or finiteness is something that I've seen as an adult general practitioner that many of my patients don't even want to go there. We have these forms for their annual physicals and do you want to talk with your doctor about end of life wishes and invariably they all check no.

But it's sort of a requirement of Medicare so I always ask them a couple follow up questions and I often get them talking. But the initial response is, I don't want to talk about death. I don't want to go there so Rs.

Mauryandi at the bare minimum requires an acknowledgement of human finitude. That acknowledgement needs to be worked out. It doesn't need to be necessarily fully worked out but attention needs to be given to these questions within the context of community.

And, you know, there are many communities, many religious traditions that have given significant amount of attention to trying to work through these questions deeply rigorously philosophically, theologically, the most attention has been given. And so what I often tell people is you don't need to get together with a group of friends and make this stuff up. You don't need to try to articulate your own answers but you do need to wrestle with the answers that have perhaps been passed down by your tradition, your religious tradition, your cultural tradition, and wrestle with whether you agree with those answers or not.

And then how does your community make sense of them? My aim in all of this is not to be prescriptive but to get the wheels turning for people because so often I've seen that the wheels just aren't turning and then folks end up, you know, God forbid with COVID in the ICU and they're young and they've never thought about this and their families are scared and, you know, more talent is high. And so it is, it is frightening for people. So one of the best things I can do is help my patients think about this early and that's really why I wrote the book.

Well, speaking of its frightening, I'd love to talk a little bit about the fear of death, which you write about. As a Chinese American my whole culture is based around avoiding death and talk about death and I shared with you earlier that I wasn't allowed to work white flowers in my hair because they're the sign of mourning as a child. So I was also struck by how you mentioned the book that Christians who actually believe in the resurrection of the body, often go to the most extreme measures around end of life care.

So what is going on there and how do we think about it the fear of death. Yeah, so in the book I actually reference a paper, two papers that were done by a group at Harvard, Michael Tracy Balboni spearheaded this work that showed that people who self identified as highly supported by their religious communities who parenthetically happened to largely be Christian, but it wasn't totally that way, but people largely Christian who identified as being fully or highly supported by their religious communities also tended to die most often within the ICU with highly aggressive end of life measures, which seems kind of paradoxical because if you believe in the afterlife, which which Christian theology spouses, then why is it that you would cling so ardently to technology. And then they did a second paper where they try to tease this out and you know part of it is thought to be due to the support that religious leaders give their congregants give the faithful to encourage them to sort of stay the course and that sort of thing, perhaps without understanding fully the merits of the technology that is applied right if technology is not actually going to do any good there's no sense using it is the thinking.

So, so, so fear of death in general, I have a whole chapter on that and I'll say this, Kathy, I don't know that that it's wrong I don't believe that it's actually wrong to fear death or that highly religious people shouldn't fear death that somehow should be a complete piece total equanimity as they stare death in the face. It's natural for us to dread extinction right that is hardwired into us. We don't want to be extinguished creatures in general, you know, aim to survive and struggle to survive creatures of all different types.

So I think there's something very instinctive in humans and other animals to try to survive. So that's it's natural to sort of fear this extinction. And also it's natural for us to dread the unknown.

When we, you know, something that we just have never experienced before which far very few of us have experienced death and by that I mean few of us have had a cardiac arrest died and been resuscitated and able to talk about what that experience was like, you know, I think it's natural, it's natural to fear death. Having said that, there are religious traditions that have tried to make the case that if you fear death then you must not have your spiritual stuff worked out. So towards the end of the book, I don't know if you remember this I talked about the Methodist who really championed I believe in the 1700s now championed last words.

And they made a lot of recording last words. And they did it not so much for the dying or the family of the dying but they did it for their community and their obituaries weren't obituaries sort of recounting the fantastic accomplishments of a person's life but they were really reports of how that moment of dying and death went. And the idea was that then this would reflect on how someone lived.

So if you didn't get so there ended up being all this pressure to get the last words right. And if you didn't get those words right then clearly you must have something wrong with your soul. And so we need to, you know, I don't know, I don't know what they did.

They sent it up becoming a problem though because people put so much stock into getting their last words right that, you know, they probably didn't attend to other matters of importance. So, so all of that is to say that we can make too much we don't want to make sort of a standard that if you have any fear at all of death you're somehow, you know, damned or not you don't have it worked out or you have installed your spiritual quest. Fear is very natural.

Having said that if fear causes us to avoid preparation, then it's in a sense, very counterproductive and in fact destructive right. So, if we can say look, I'm mortal I'm never died. It's a bit scary.

I'm not exactly feeling peaceful about it. But we press into that. We walk in, we walk toward the fear with our communities, working through these questions I think that gets us closer to where we want to be, then if we just let fear keep us from going there all together.

Does that make sense. Yeah, it does. Thank you.

I'm just struck a little around the paradox it seems like and you touch on this I think in your book about is death something to be embraced or is death something to be. Is it a bad part of creation. And sort of a theology of death.

How do we think about death? Do we fight it? Do we embrace it? Yeah, yeah so that's a great question so my big caveat is I'm not a theologian. I don't play one on television so you know take all this with a grain of thought, but there is a theologian who's worked on this question, particularly with regard to the arts more indie and whatever hey at Duke who is no longer with us. But he's written a lovely book, in a sense analyzing the theology of the arts more indie and his big criticism is that the arts more indie commended death.

And as you look at the language of one of the very early English versions of the arts more indie, the dying is called to die willfully and gladly. And you know, most of us, whatever right I mean dying willfully and gladly. I suppose that that sounds great if you're a martyr right but if you know most people are not martyrs and it seems a little bit perverse to say that that's the way we should die and that's Professor Verhay's big criticism.

And he's got a lovely book so I commend it to you. So, so we don't necessarily want to commend death in the way that the arts more indie did. As a non theologian my understanding of Christian theology on death is that there is a paradox.

So there's a way in which death deals a terrible blow. And this idea of the sting of death, it hurts, it tears holes in our community, it rips family members away from us you know all of this it's a very painful experience. Yet, while you know Christian theology holds that there is this, this horrible side to it, the whole point of Christ resurrection, Christians believe is that this demonstrates that death does not have the last word that in fact Christ resurrection shows that death death will be defeated death has been defeated and those of us who are anticipating our own deaths and still a little bit unsettled about it really can put our confidence in the fact that there will be a bodily resurrection as exemplified with Christ at some point in the future.

So that's where Christian theology is as I understand it holds these two intention yes it's horrible yet, it has already been defeated and we can hold on to that promise so so I think that's, that's what Christian theology gives us on death. Yeah, you might invite the theologians back right now we're thinking about death we're thinking about mortality we're thinking about all these things because it's very in our face. And I don't know if we're ever going back to normal life, but if we do go back to normal life what questions should we ask ourselves, what should what should we press ourselves into now, so that we would be able to practice this, or as more likely better, or number our days without fear.

Yeah, there's a way in which the, the anticipation of death or the confrontation with mortality should help bring into relief that which we most value, right, and it should help us work to determine what gives our lives worth and, and as we identify what gives our lives worth meaning and what gives our lives meaning, or worth, then we work toward that in the context of community again always in the context of community. And so, you know, here I'm, I'm reminded of this up song 90 that talks about numbering our days so that we gain a heart of wisdom. There's a way in which when there are boundaries, we know what we have to work with.

And the fact of the matter is in the pre COVID era, it was hard to really see many limits on our lives, especially maybe the younger, healthier folks. And, and you know the economy was going very well unemployment was low, you know what you could fly to Europe for $400 what wasn't there to love I mean that sort of the world was our oyster. And that's very different now.

It's very different now in such a short time. And so now that we are sort of sobered up. I think it would it would behoove us all to give good attention to how we make sense of our of our finitude of our numbered days, so that then we can reflect back on what we need to change what we need to do differently.

And that was the work of a lifetime. The arts more Andy was under no illusion that this was a quick fix. There was there's one scholar early scholar of the arts more Andy who who said this was a handbook that was at the bed of every dying individual but actually it was the same content that was practiced by the communities that surrounded the death of the dying, you know, so this was the work of everyone even children had a role to play in the there were ways that the children participated so from very early on and again these these pre modern years were years when death was was much more common.

It was very common for children to die and and it was really only those who got past their 40s that then would survive into what we think of as old age but people death was much more common. So, so by attending to the dying, people were able to practice to put into practice, just again some of the cat heikisms and protocols reminding themselves of what they believed. And there's also part of the arts more Andy the very early versions that said look, even if you were a secular man right so even if you were sort of outside of the church there's still was content for you here.

There's still a way and that was one of the things that drew me to the arts more Andy originally. There's content for everyone, even if you, you don't, you don't have worked out what you believe where you don't even believe what your community believes. I think it's a work for you to do there's a way in which you participate in this.

I like, I like thinking about this is in some ways the cultivation of the virtues, you know going back to ancient Greece and thinking about having to cultivate, you know, ancient Greece it was what prudence and courage fortitude things like that. There are things we need to work on, and if quarantine hasn't given you opportunities to see your own flaws is certainly has given me many opportunities to see my own weaknesses and I have realized very much how, you know, things I need to work on patients for my kids, for example, you know there's stuff, stuff we have to work on. And we cultivate those excellences or those virtues, we practice them and practice them and practice them.

And that's that's sort of the work of the arts more Andy we practice these things in community over the context of our lives. Such that we die die well die better, hopefully than if we gave no thought to this at all. For those who are working with undergrad students who are not thinking about their own mortality at all.

Is there do you have any best advice for working with young folks around these questions of death. Interesting. So I work with med students and even my first year medical students have been really struck by COVID and mortality in a way that they hadn't been three months ago.

So I do think there's something unique about the moment asking people about how they're feeling in this moment. Having said that the other people who are completely outside of areas that have been hit and don't quite experience it in the same way. It is true though on the whole that younger folks haven't confronted death in quite the same proximity.

Usually in a room of undergressed there's only a couple who have even experienced the loss of a grandparent or entraumplers something so sometimes literature is great. I have taught several times on Nathaniel Hawthorne's The Birthmark which asks other questions particularly if that are good for challenging conventional paradigms of how we think about disease and illness, but also ask ultimate questions. So literature poetry can be very, very effective in working toward this.

And last question, what can those who are acutely aware of and anxious about their mortality due to live well. I think the things that we've been talking about. Certainly, certainly reading and discussing in the context of community is really important.

There are secular versions of this. There's a non religious context so the death cafes has been a movement in recent years to try to bring death into the conversation it's death cafes occur in a lot of urban centers where groups of people who are sort of think that these issues get together, usually and try to talk about wrestle through mortality. I always, I do think whatever one defines as one's community and that is often religious or spiritual in nature is probably the best place to start.

I mean I've lectured at churches that have been working through this and brought me in on a Saturday kind of thing to, to, they'll be reading a book like a tool go on days book and I come in and sort of, you know, do a little thing. But, but I think it's important to just press into it. And, and not to fear it is fearful there's there's no reason to be ashamed of the fear related to death, but to, to press into conversation and contemplation and read and talk with people but not to do this in isolation I think is the most important element.

And it does seem like in this time and age, the feelings of isolation are huge. As we're forced to isolate so any suggestions about that in the time of COVID. You know, I think everyone should call up a friend and go for a walk with a face mask on and stay six feet apart.

We need to be in relationship. And I've spoken to so many people who are struggling right now, especially single people who don't have families to make them insane during these days. It's a very lonely experience but there's a way, I mean I go to the hospital right I'm still teaching and some of that is in person, certainly my clinical care is in person and we do that safely.

And so there's a way that we can be in community safely and going for a walk outside in the sunshine keeping some space and wearing a face mask. And that's about as good as you can get. That's what we do in the hospital.

And, but I think we need to push toward community because the isolation and certainly the mental health repercussions of that and the spiritual health repercussions of that can be very very destructive and so, so sort of working toward community and fits and starts and then safe groups and things like that is definitely what we want to push toward. I think most people are ready for that and there are ways that it can be done well. If you like this and you want to hear more like share review and subscribe to this podcast.

And from all of us here at the Veritas Forum. Thank you.

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