To me, in this profession, at its simplest level, heroism is acceptance of our own mortality. And that is where we all — doctors and laypeople alike — must draw on our courage.
I attended a conference called “Mindfulness in the ICU” at the University of California, San Francisco, several years ago. I was at once intrigued and baffled. At the time, the title of the conference struck me as an oxymoron. Can one be mindful in an ICU, where every second counts? Should one? Taking even a moment to breathe or to reflect seemed a bit risky to me at that time.
Yet I had been hearing more about mindfulness, a modern spin on meditation, and had even taken an eight-week course from StressCare, one of a number of new groups introducing this tool to the lay public. StressCare had been recruited to train residents and staff at UCSF, and so it felt like a legitimate, serious organization. Moreover, the conference was being led by Dr. Mitchell Levy, an ICU hero doctor if there ever was one. An associate professor of medicine at Brown University, Dr. Levy had been one of the lead investigators for the Surviving Sepsis Campaign in 2002, from which had emerged the widely accepted approach to managing critically ill patients with sepsis, one of the ICU’s most common and lethal conditions. If he was the sponsor of this conference, it couldn’t be too “out there” for me to try.
Dr. Levy was also the chair of the Robert Wood Johnson Foundation’s critical care end-of-life workgroup. He had started lecturing about the lack of mindfulness among physicians, which he believed contributed to their problems in caring for their patients and for themselves. He believed that teaching mindfulness to clinicians would enhance their abilities to serve their patients by being able to hold space, slow down, and really listen. And he also postulated that if physicians learned to soothe themselves in their work environments — especially places like the fast-paced ICU — everyone, patient and physician, would do better.
In reading about him, I learned that Dr. Levy had been a practicing Buddhist since his college days. His bio stated that he was a senior teacher in the Shambhala Buddhist tradition and that he drew from his Buddhism in an effort to teach communication and compassion skills to medical professionals.
It was a daylong workshop and I arrived at 8:00 a.m. After the attendees grabbed coffee and Danishes, we were asked to take a seat in the main room. It was set up very differently from most conferences, the chairs in a large circle. Dr. Levy introduced himself and then asked people to go around the room introducing themselves to the group. I was disappointed, although unsurprised, to find that physicians were in a significant minority. Most of the people attending were nurses, with a smattering of physical therapists, respiratory therapists, and administrators.
Dr. Levy didn’t look like a Buddhist, I thought. He looked like a doctor, with a blue suit and tie and white cropped hair. The only thing that struck me as Buddhist was that he had removed his shoes. Unusual, but it seemed quaint and lent an atmosphere of authenticity to the experience. He smiled at the group, slowly looking around the circle, acknowledging each of us individually. “Who here has pictured his or her own death?” he asked quietly. There was silence, then a few nervous chuckles. Then a couple of hands rose tentatively. Not mine. He went on. “How can we expect to help our patients plan for their deaths if we haven’t planned for ours?” He waited, not so much for a response but for his words to sink in. The room was quiet, but Dr. Levy seemed to expect it. “I’d like us to do an exercise where we picture our own deaths,” he said. “Who would be there? What would they be saying? Who would be crying? What would you have not gotten done? For what would you be grateful? Who would be holding your hand? Who would be standing at the foot of the bed? In the hall?” And with those instructions, he fell silent and closed his eyes. And so did we.
I realized that although I was around death every day, I had never before allowed myself to consider my own. It was as if I had willed myself immune to it.
But now I let it seep in. The sadness. The uncompleted tasks. The things I would miss. The weddings. The grandchildren I might never meet or see graduate. I saw my children crying. I saw their kids growing up without knowing me. I imagined my husband remarried, a new wife living in my house, stepmother to my children, grandmother to my grandchildren.
But then I began to consider whom I would want to be next to me. And what I would say to them. The words of encouragement, the instructions I would give them. I imagined the unknown, which may not be all bad. And the tears started to fall down my cheeks. One big fat one at first, brimming over and paving a salty track down my dry cheek to come to an embarrassing stop at the corner of my mouth. I wasn’t sure if I should lick it or ignore it. And thus my mindfulness exercise ended because I needed all of my focus to suppress my impending sobbing. I was relieved when Dr. Levy took in a deep breath and rang a bell concluding the meditation. I had been saved from the mortification of being an ICU physician sobbing uncontrollably as I pondered my own death. And right in front of the nurses, physical therapists, and respiratory therapists that I feel I must stand before confidently, never wavering in my resolve that I can make it right for my patient.
In all my years of practice, it was the first time I had truly faced my own death. It’s not that there hadn’t been opportunity. Every year at the Rosh Hashanah (the Jewish New Year) service, I read aloud the prayer Unetaneh Tokef (Let Us Cede Power). This prayer attests to our lack of control over our mortality, willing us to repent and mend our ways in order to be inscribed in the Book of Life for another year. Its words are sobering, even grisly.
On Rosh Hashanah it is inscribed, and on Yom Kippur it is sealed:
how many shall pass on, and how many shall be born;
who shall live, and who shall die;
who in his time, and who before his time;
who by fire and who by water;
who by sword and who by beast;
who by hunger and who by thirst;
who by storm and who by plague;
who by choking and who by stoning . . .
who shall rest, and who shall wander;
who shall be tranquil and who shall be harassed;
who shall be at peace and who shall suffer;
who shall become poor, and who shall become rich;
who shall fall and who shall rise . . .
But somehow it never felt real. These types of deaths — by stoning, drowning, thirst, or sword — always felt strange, ancient, more of an attestation to ritual than to reality. They had nothing to do with me.
But sitting in that circle, I finally let it in, the hard fact of my mortality. Opening to the sadness, I realized I’d been running away from it. I began to think more deeply about how I would help all of those walking that path before me. How could I possibly help my patients accept their deaths if I hadn’t stopped to accept mine?
I am, of course, no different from my patients, no better or worse. Often no wiser. And no more entitled to live another day. I reminded myself that death comes for us all, and sooner or later, I will be the one in that bed, on the other end of the stethoscope.
I considered what type of doctor I would want to have with me as I made these final decisions, as I breathed my final breaths. It would be one who would strive to know who I was and what was most important to me. One who would counsel my family members if I could not speak for myself. Who would alleviate my suffering, make sure I never felt abandoned or scared, that all of the pieces were in place. And then allow me to pass peacefully into that good night.
Reprinted from EXTREME MEASURES by arrangement with Avery Books, a member of Penguin Group (USA) LLC, A Penguin Random House Company. Copyright © 2017, Jessica Nutik Zitter, MD
Jessica Nutik Zitter, MD, MPH, is author of EXTREME MEASURES: Finding a Better Path to the End of Life (Avery Books, Feb. 21). An expert on the medical experience of death and dying, Zitter is double-boarded in pulmonary/critical care and palliative care medicine. Featured in the Academy Award™ nominated 2016 Netflix documentary Extremis, she is a graduate of Stanford University and Case Western Reserve Medical School, and completed her residency in internal medicine at the Brigham and Women’s Hospital (Harvard Medical School).
Originally published at medium.com