It's a Matter of Choice: Considering Physician-Assisted Death ...

Ultimately, in our view, when beneficial medical options for cure and for palliative care diminish, the patient, after being properly informed, increasingly becomes the final arbiter in accepting or rejecting these options.

Gerrit Kimsma, MD and Evert van Leeuwen, PhD (2004)

Hello, Everyone,

I'm late with this post after waiting for and then pondering how to respond to the Supreme Court's decision to allow physician-assisted death in Canada. In the end, I think all I can do is to tell my husband's story and to highlight a few important concerns.

On September 30, 2004, my husband of almost twenty years died three weeks after stopping all treatment but palliative care so that his viral cardiomyopathy could run its course. It had been 7 years since his diagnosis and he'd spent the last 3 years confined to bed. He was not clinically depressed and, despite a considerable amount of grief, had been a wonderful role model for how to live life fully and well with ever diminishing energy and abilities. He taught us how to live well and, when the time came, how to die well.

When he told me of his decision to stop treatment, he put it this way. "I feel like a weary traveller on a railway platform waiting for the train. The only thing that makes me sad is knowing that you won't be coming with me." He was exhausted, suffering and ready to die. Any exertion, even listening to music with a quick tempo, caused him chest pain;  every few days he was subjected to the uncontrollable and excruciating pain of catheter changes with a hypersensitive bladder; and the loss of control, pain medication and diminishing oxygen to his brain triggered frequent posttraumatic stress flashbacks to his childhood in wartime England. He had had enough and, although I didn't ever want to lose him, I supported his choice so his suffering could end.

Would he have chosen a physician-assisted death if it had been available at the time? I honestly don't know. But, aware of his lifelong desire to have and carefully consider options in any situation, I think he would have wanted to consider the possibility. (And I'm quite sure that I will want to consider the possibility for myself when the time comes.)

Several things concern me as we wade into the early days of implementing this decision. Three of the most important follow. The first is that we need to see physician-assisted death as part of the continuum of care rather than as a separate choice over and against disability-support and palliative care. Such dualistic thinking will only cause more grief and suffering to patients and families. It is not a matter of either-or but of both-and. Yes, we must improve the quality of and access to sufficient and wide-ranging disability, palliative and hospice care but that doesn't mean that we cannot also provide assisted-death to the few whose suffering cannot be eased and who request that final option. As Dutch physician, Kimsma and medical ethicist, van Leeuen, put it in Physician-Assisted Dying: The Case for Palliative Care and Patient Choice:

(Placing euthanasia in opposition) to palliative care in the way critics have suggested fundamentally disregards the wishes of the patient in the face of death.

Surely that is not our purpose in providing end-of-life care?

A second concern is that we should make our choices regarding the implementation of this decision based on research and compassion rather than on our fears. For example, we know that despite some fears that people will be "put to death" in terrible circumstances, in-depth interviews with patients and families in other jurisdictions point to assisted-death as a moving and positive experience with less traumatic grief experienced after the death than that found in counterparts whose loved ones had died a "natural death". Other studies tell us that physicians can have a very difficult time, emotionally and in relationship with their families, in the days before and after assisting with a death, calling into question the fear that they will become inured to the experience and begin to make such decisions too easily. There are many cases in which our fears regarding physician-assisted death can be allayed by the facts. So, let us be sure to examine the evidence before allowing fear to determine our actions.

My third concern is based on the physician studies noted above. If we are to begin offering patients physician-assisted deaths, it is vital that we first have conversations about what comprises adequate support for the health-care professionals involved. It will be important to put our knowledge of compassion fatigue and burnout to use in creating the best possible support for these caring people.

I believe that if we are open-minded, reflective, compassionate and wise, physician-assisted death can become another important tool for providing comprehensive and compassionate end-of-life care.

How to Make & Keep New Friends ...

The ultimate touchstone of friendship is not improvement, neither of the other nor of the self, the ultimate touchstone is witness, the privilege of having been seen by someone and the equal privilege of being granted the sight of the essence of another, to have walked with them and to have believed in them, and sometimes just to have accompanied them for however brief a span, on a journey impossible to accomplish alone.

Hello, everyone,

The above quotation is from a lovely new book of prose called, Consolations: The Solace, Nourishment and Underlying Meaning of Everyday Life, written by the much-loved poet, David Whyte.  In it, he writes short but profound reflections on fifty-two words from our everyday lives - from alone to ambition, denial to disappointment, forgiveness to friendship and vulnerability to joy.

While reading the four pages given over to friendship, I was reminded of a workshop participant who approached me after a workshop last fall to say that he had enjoyed the day but that several of the resilience suggestions had involved doing activities with friends or "self-care buddies" and he didn't have any friends, other than his wife who was living with a life-threatening illness. I was stunned, both by my thoughtlessness in not considering that possibility and by the depth of his sorrow and isolation.

In fact, this gentleman was probably not the only person in the room feeling a lack of connection. Those of us who have experienced the kind of trauma or loss that created our hypersensitive empathy as helpers, can also have difficulty forming and sustaining close relationships - until we've done some of our healing work. The same primary traumatic stress that contributes to our compassion fatigue also gets in the way in our everyday relationships.

But we need those relationships. Friends are necessary to our health and well-being and to our compassion fatigue resilience. As David Whyte says, they stand witness to our lives. They also help us through difficult times. They celebrate our successes. They show us the world through a different lens. They boost our mood. They improve our health. And, at their best, they help us to become our best selves.  

Once we've done some of our healing work, we can practice developing healthy friendships. Here are a few steps to try:

1.  Meet some new people:  The first step is to find people with common interests. This means determining your own interests and then finding ways to meet others who share them. You might want to try volunteering (in an area different from your work if you have a high trauma exposure there); take a class; join a club; walk a dog in a dog park; invite a neighbour, someone from your spiritual community or a work colleague to go for a walk or to a movie; try carpooling; connect with your alumni association; look for old acquaintances on the internet; attend art gallery openings, book readings, lectures, or music recitals or go to favourite recreational or sporting events. 

2.  Learn to engage in conversation: Not everyone has had the opportunity to learn how to converse with others. If you don't know how, or are feeling rusty, try one of these suggestions to open a conversation. Remark on the surroundings or the occasion. Make an honest compliment. Ask an open-ended question (one that requires more than a yes or no answer). Notice anything you have in common with the other person then ask follow-up questions. Keep the conversation light during the early days and avoid potentially divisive topics like politics or religion. 

Learn to pace the sharing of your personal history. It's generally not helpful to share your deepest, darkest secrets on the first meeting because you might then feel too exposed to meet again. Share just a bit of yourself at a time and then imagine yourself sitting on your own shoulder observing the interaction. If your information is received kindly, then you can risk sharing a little more. If it is received disrespectfully, note that and don't go any deeper.

The flip side of conversation is listening and it pays to learn to listen well. Really pay attention to what the other person is saying and encourage them to continue, using verbal cues like saying "yes" or "uh huh". (Note that it is not "good listening" to immediately follow someone's story with one just like it from your own life. People don't necessarily hear that as an empathic response. Continue to keep the focus on them for a while.) 

3.  Be a good friend:  Try to live by the golden rule in your friendships - do unto others as you would have them do unto you. Follow through on commitments. Be thoughtful. Keep confidences. Share yourself and your time within the limits of your own needs. 

Support and encourage your friends. Invest in the relationship but don't be too dependent or clingy. It takes time for a relationship to evolve - let it happen naturally and give the other person space to breathe. 

Learn to apologize and to forgive. Everyone makes mistakes and there will be conflicts in most relationships. When there's a problem, address it calmly, directly and honestly and find a way to work it through. It is this working through that deepens our intimacy.

Should any of these suggestions fail and a budding friendship not work out, try not to take it too personally. The other person may have something else claiming his or her attention or just may not be up for a new relationship at the time. If this happens, as the song lyrics say,  pick yourself up, dust yourself off and start all over again.

Good luck!

A Friend Indeed ...

Hello, Everyone,

This morning, I want to say a bit about friendship, having learned of the death of an old and dear friend, Susan (Mitchell) Voth, on the first day of this new year. (My heartfelt condolences to her family and friends.)

I met Susan in 1970 during my urology rotation in nurses' training at St Paul's Hospital in Vancouver.  I was an eighteen year old junior surgical student and she was a relatively new RN from the Maritimes who kept everyone - patients, students, staff and physicians - in stitches much of the time. While she struggled with a learning disability that made her handwriting and spelling atrocious, she had the kind of natural wisdom and intuitive knowing that made her an invaluable partner on nightshift when a patient's condition was going south and the issue hadn't quite declared itself. Her heart was as big as all outdoors and she stayed in touch with many of her patients and families over the years.

Susan and I became fast friends during my training days and were roommates, on and off, over ten years until each of us married. She and her first husband, Al, who was later killed in an airplane accident, moved to the prairies to farm and we eventually lost track of each other. I was happy to have the opportunity to reconnect with her briefly when she visited Vancouver years later after marrying her second farmer husband, Henry.

Susan was a good friend to me and I realize, now, that we understood each other so well because we  shared the effects of our particular childhood trauma - Susan had lost her mother at the age of two and I had experienced significant medical trauma and maternal separation at birth. We had also lived through many years of our fathers' alcoholism. Those shared experiences gave us a natural empathy for each other and our friendship helped fill many gaps from our younger years.

From Susan, I learned to cook, camp, canoe, enjoy a little good scotch, choose a good lobster, like pop music, socialize in large groups (I was very shy), play my guitar in public, drive a car (first a volkswagon beetle, then an MG Midget and finally a volkswagon van that took us 23,000 miles around North America in 1978),  to laugh more and worry less, and even to recognize that I had a spiritual life worth developing (though our paths-of-the-spirit soon diverged). Her family - her Dad, Helen, and siblings, Nancy, Peter and Mary - welcomed me into their homes and offered rich adventures on the ranch in Manitoba; in Cornerbrook, Newfoundland; on the St Stephen, NB - Calais, MA border; and by the sea in St Andrew's, NB, adventures that I would never have had otherwise and will never forget. I owe a debt of gratitude to each of them.

We know from the literature on trauma and social bonds that all human beings need social support to survive and thrive. When we have someone we can trust with our stories and our feelings and from whom we can receive support without judgement, we heal better and faster from the wounds of life.   Susan was one of the first of a large network of valued family and friends who have provided that kind of friendship to me. I am forever grateful.

If you have a friend or friends who have been particular supports to you, why not take some time today to think of them and their value in your life and then, perhaps, pick up the phone or write a note to tell them, specifically, how much they mean to you and why.

If, on the other hand, you're feeling isolated and alone and can't even think of a person you'd call a friend, watch this space next time when we'll look at the process of making friends. (An important skill for those who have never had many friends or whose support networks have shrunk significantly through ongoing care-giving or compassion fatigue.)    

 

New Year's Rituals ...

Happy New Year, Everyone!

I hope you've had a restful and refreshing holiday season.

I'm just back from visiting my surrogate family in Nanaimo (on Vancouver Island) and it's time, now, to put the holidays to bed and to greet 2015. I have a few rituals I've developed over time that help me to consciously cross the threshold into a new year:

1.  Cleaning Up the Old and Welcoming the New

My first ritual is to tidy away all the holiday decorations and pack the boxes into the crawl space, ready for next year. That always leaves the house looking a little drab and mournful so I've learned to do two things, apart from the usual house cleaning and pine needle collecting, to brighten things up a bit. The first is to wash all the windows and all the curtains, which somehow seems to let in a little more light even on our rainy, grey Vancouver days.

The second thing is to take an early morning drive to Granville Market and splurge on a couple of bouquets of brightly-coloured flowers to replace the sparkle of the holiday lights. What a difference these two simple acts make to my perception of the winter days yet to come. 

2.  Reflective Journalling 

Once the house is back in shape, I like to light a big fire and settle down next to fireplace with a cup of tea and my journal to do some reflective writing about the year ahead. This year, I used as a guide,  Parker J Palmer's, 5 Questions for Crossing the Threshold, based on a poem by Anne Hillman:

We Look With Uncertainty

We look with uncertainty

beyond the old choices for

clear-cut answers

to a softer, more permeable aliveness

which is every moment

at the brink of death;

for something new is being born in us

if we but let it.

We stand at a new doorway,

awaiting that which comes ...

daring to be human creatures,

vulnerable to the beauty of existence.

Learning to love.

• How can I let go of my need for fixed answers in favour of aliveness?
• What is my next challenge in daring to be human?
• How can I open myself to the beauty of nature and human nature?
• Who or what do I need to learn to love next? And next? And next?
• What is the new creation that wants to be born in and through me? 

3.  Choosing a Word (or letting a word choose you) to Guide Your New Year

This last ritual is one I've been using for the past five years. I first learned about it from my friend, Elaine, who read about it in an Abbey of the Arts newsletter. I find it a wonderful way to focus my attention on an area of discovery and growth for the whole of the new year. I've written about the process of "receiving your word" here.

What about you? How do you mark the transition into a new year?

Wishing each of you a New Year filled with hope, promise and possibility,

Jan



(Photo by Janet Ritchey)

   

Christmas Peace ...

Hello, Everyone,

I've finished the cards, the gift wrapping, the baking and the house-cleaning and I'm now looking forward to a few lovely days of sparkly lights, familiar carols, shared meals and the warm hugs of family and friends.

To each of you, whether anticipating a happy Christmas or one of weariness and stress, I wish a deep sense of peace, the peace that transcends understanding and that is so well described by Goethe in his beautiful poem, Peace:

Peace

There is only silence

On the mountain tops

Among the tips of the trees

You perceive barely a breath

Even the birds in the forest

Keep still and are silent

Wait then

Just a little while longer

And you too

will find peace at last.

                   (JW von Goethe translated by Patrizia Collard) 

May each of us find the peace we seek this holiday season, whether in the quiet of Nature, the beauty of a religious ritual, the arms of a friend or at the bedside of a loved one.

With love and deep peace to you all,

Jan

Welcoming What Is ...

Hello, everyone,

How are you feeling today?

The winter holidays are times when we can experience a wide range of emotion from excitement, anticipation, hope, pleasure and joy to guilt, loneliness, anger, regret and sorrow. It is our natural human tendency to embrace the joyful feelings and to ignore, push away or brace against the painful ones. Unfortunately, resisting our painful feelings only makes them stronger.

So, what if we made the counter-intuitive decision to stay present to whatever we feel, whatever is, and even to welcome our painful feelings? What if we decided to practice a kind of "inner hospitality", responding to each painful feeling as we would a small child -  noticing it, acknowledging it, welcoming it, letting it be but not letting it overrun the house? Paradoxically, what we might find if we engaged in such a welcoming practice is that the painful feelings would begin to soften or shift of their own accord.

This notion of "welcoming" is found in different forms in many schools of psychology and spirituality. Basically, it comes down to a few simple, though not necessarily easy, steps:

1.  Focus and sink in. Feel the feeling. Don't ignore it, run away from it or fight it. Stay with the experience until you really feel a connection to the physical sensations of the feeling in your body. 

2.  Accept and welcome the feeling. In the midst of your upset, accept and welcome how you feel. Embrace your feeling with love, kindness and warmth. Say, "welcome", to it and experience the welcoming home of this part of yourself.  "Welcome, fear." "Welcome, anger." "Welcome, sorrow." 

Remember that you're not welcoming an event or circumstance but rather your feeling response to it. For example, the welcoming practice is not about welcoming an illness or injury or losing your job or being abused but about welcoming your feelings about those circumstances.

3.  Swing gently and slowly, back and forth between sinking into the experience and welcoming it, until the feeling softens or shifts or, as one writer says, "until the knot begins to dissolve".

This welcoming practice is not about analyzing or justifying our feelings. It's not about trying to change or fix them. It's about be-ing with them and welcoming them home so we can receive their messages and make them part of our wholeness. When we welcome our feelings in this way, we can stay present to ourselves and what is, no matter what our circumstances. And, as we stay present, we will find that even our painful feelings are ultimately transient.

The 13th Century poet, Rumi, seemed to understand this idea of "welcoming what is", into our lives. Here's how he described it in his poem, The Guest House:

This being human is a guest house.

Every morning a new arrival.

A joy, a depression, a meanness,

some momentary awareness comes

as an unexpected visitor.

Welcome and entertain them all!

Even if they are a crowd of sorrows,

who violently sweep your house

empty of its furniture,

still, treat each guest honourably.

He may be clearing you out

for some new delight.

The dark thought, the shame, the malice,

meet them at the door laughing and invite them in.

Be grateful for whatever comes

because each has been sent

as a guide from beyond.

If you would like to know more about the idea of welcoming painful feelings, from a couple of different perspectives, you could read Eugene Gendlin's book, Focusing, or Cynthia Bourgeault's writing on the Welcoming Practice in Centering Prayer.

  

Caveat:  This welcoming practice is probably not the best practice for anyone who is acutely traumatized, actively misusing substances, in early recovery, clinically depressed or with a history of psychosis or difficulty tolerating their own feelings. If you fall within one of these groups, talk to your family physician or therapist before beginning an ongoing welcoming practice.

My Favourite Comfort Books ...

Hello, everyone!

My apologies for the hiatus in posting. It's been a particularly busy month with workshops and talks interspersed with treatment for my recently diagnosed normal-tension glaucoma. I'd forgotten, (with the same kind of denial a mom uses to "forget" the pain of labour so she can do it again), how time-consuming specialists' visits, tests and treatments for chronic conditions can be. While I have some vision loss in one eye, my pressures have stabilized, I've managed to avoid surgery and I have time, once again, to enjoy writing some holiday posts (and perhaps, some new workshops for 2015).

Reading has always been one of my favourite comfort activities so I thought I'd share with you a list of my favourite "comfort books" for your own reading pleasure and, perhaps, for holiday gift-giving:

1.   The Guernsey and Potato Peel Pie Society by Mary Ann Shaffer and Annie Barrows (2009)  I hugged this book when I finished reading it for the first time in 2009 and I've read it at least twice since. Set in 1946 and beyond, the story is revealed through a series of letters between an author, Juliet Ashton, who is searching for ideas for her next book and members of the Guernsey Literary Society. Fascinated by the people she is meeting through the letters, Juliet decides to go to Guernsey to meet her new friends. This book describes both life in WW II, German-occupied Guernsey and the invincible spirit, humour  and honour of the people who lived through those times.

2.  The Two of Us: My Life With John Thaw by Sheila Hancock (2004) This wonderful biography/autobiography of British actor, John Thaw, (Morse, Kavanaugh QC, Goodnight, Mr Tom) by his wife, Sheila, (also a well known British actor) provided me with unceasing comfort and the affirmation that I wasn't losing my mind through the early years following my husband's death and I still pick it up from time to time ten years later. It, in concert with its sequel, Just Me, is the best book on spousal grief I've read. Interspersed with stories of their early lives are moving, emotionally honest, italicized segments from Sheila's journals, tracing John's diagnosis with cancer, Sheila's caregiving and her early struggles with bereavement. A sometimes painful but ultimately heartwarming story of strength, hope and deep spousal love.

3.  Listening Below the Noise: A Meditation on the Practice of Silence by Anne LeClaire  (2009)  This eloquent little book sits on my bedside table and I dip into it from time to time just to enjoy the beauty of the writing, let alone the wisdom of the words. Anne LeClaire, a novelist and journalist, shocked her husband, children and friends by deciding to spend every 1st and 3rd Monday in silence. To say that it disrupted the pattern of their lives is an understatement and there was plenty of pushback. But eventually, they  began to learn what she was learning - that in silence lies joy and a much deeper connection with oneself, with others and with Nature.

4.  Kitchen Table Wisdom: Stories That Heal by Rachel Naomi Remen, MD  (1996/2006) My husband read this wonderful storybook before I did and couldn't resist interrupting what I was doing to read lengthy excerpts out loud. Rachel Remen, a physician, medical educator and patient with a severe chronic illness, writes stories of hope, humour and joy that remind us that even the worst circumstances can bring us experiences of mystery and growth. These stories were a source of comfort and healing as I recovered from my second bout of compassion fatigue.

5.  To Bless the Space Between Us: A Book of Blessings by John O'Donohue (2008) I love this book of blessings and have quoted it often in my workshops and in this blog. John O'Donohue describes a blessing as a circle of light drawn around a person to strengthen, heal and protect. His blessings, steeped in Celtic spirituality, offer comfort and encouragement in situations as varied as beginnings, desires, thresholds, homecomings, states of the heart, callings and endings. 

6.  Enchanted April by Elizabeth von Arnim (1922/2014) This is a gentle story of four very different women from 1920's London who travel to Italy to escape loneliness, sorrow, dreariness and the dissatisfaction of exploitative and overbearing relationships. Once away from the unending winter and greyness of their lives in England, they settle into the sunny warmth, simplicity and undemanding rhythms of a country guesthouse and slowly begin to come to life. I love the book and the British movie by the same name and return to both again and again.

7.  Winter Solstice by Rosamunde Pilcher  (2000) Written in Rosamund Pilcher's warm and evocative style, this story of later-life love, loss and healing weaves through difficulties and tragedy to a thoroughly satisfying Christmas ending in a rambling house in Northern Scotland. If you're looking for an easy and predictable but heartwarming read to help you transition to the spirit of the holiday season, this is it.

8.  Why I Wake Early: New Poems by Mary Oliver (2004) Anything by Mary Oliver is comfort reading for me. I especially like this volume which includes poems on crickets, toads, trout, lilies, goldenrod, bears, greeting the morning, watching the deer and lingering in happiness. Reading Mary Oliver is like going for a silent walk through woods and meadows with a very dear friend - absolutely perfect.

9.  Girl of the Limberlost by Gene Stratton-Porter (1909) I first read this inspiring book when I was about ten or twelve years old. It tells the story of Elnora Comstock, an impoverished girl living in the Limberlost who, despite her father's tragic death and her mother's strict and bitter parenting, manages to "lift herself above her station", excel at school and become a gifted violinist. Any time I feel discouraged about life, I go back and reread the story of this spunky young woman who overcame so much to find the happiness she sought.  

10.  Christmas With Rosamunde Pilcher by Rosamunde Pilcher  (1997)  I'm not sure why I love this book so much but every year I bring it down from the bookshelf on the last Sunday in November to mark the beginning of the holiday season. I settle in front of the fire with a glass of eggnog and with Marty Hagen's Night of Silence playing on the stereo and carefully turn the shiny smooth pages taking in exquisite photos of winter in Scotland and of the Pilcher family preparing for and enjoying their family Christmas. Then I snuggle more deeply into the chair to read from the last third of the book, a lesser-known Pilcher short story, Miss Cameron's Christmas. This gentle tale of family caregiver, Miss Cameron, and of the kindness of neighbours at Christmas time never fails to lift my heart and to begin the season on exactly the right note.

So, these are ten of my favourite comfort books. What about you? Are there stories you might like to re-read yourself or to give friends, children or grandchildren as a gift of comfort this holiday season?