#354 – What the dying can teach us about living well: lessons on life and reflections on mortality | BJ Miller, M.D. and Bridget Sumser, L.C.S.W.

The physiological and psychological landscape of dying is explored in this podcast segment, as BJ Miller, Peter Attia, and Bridget Sumser discuss the body's natural shutdown in the face of death and the complexities of the emotional experience associated with dying.

The Body's Natural Shutdown Process as Death Approaches

Body Systems Shut Down Preparing For Death

BJ Miller articulates the physiological changes that happen as the body prepares to die, emphasizing this is a natural process. He mentions that intervention often occurs during the natural shutdown of the body, a pathway shared by various causes of death such as cancer, heart disease, and neurodegenerative diseases. Miller notes that this includes the organ systems shutting down in a non-linear pattern, with kidneys ceasing to function, prompting a buildup of toxic metabolites leading to reduced urine output.

Delirium and Altered Mental State Near End of Life Need Careful Understanding

As the physiological body systems shut down, the resulting altered mental states, including delirium, need careful attention. Miller points out the commonality of such mental status changes toward the end of life, where confusion and disorientation are typical. Delirium, with hyperactive and hypoactive variants, can often be overlooked, especially in its quieter hypoactive form. Families and loved ones are urged to recognize delirium to avoid misinterpreting a patient's words or behavior. This altered consciousness is managed with careful treatment in both hospice and ICU settings.

The Emotional and Existential Challenges Of Facing Death

Dying Process Can Threaten Identity and Reality Through Fear, Grief, and Uncertainty

Peter Attia questions how connected and cognizant patients can remain during their final days, given symptom constraints, medication load, and states of delirium. Bridget Sumser adds that connection can still occur, such as through storytelling or physical touch, even when ...

The importance of palliative and hospice care, and the systemic challenges these services face within the healthcare system, come to light through conversations with experts BJ Miller, Bridget Sumser, and Peter Attia.

Differences and Overlap Between Palliative Care and Hospice

Peter Attia and Bridget Sumser discuss distinguishing between palliative care and hospice, with palliative care focusing on quality of life and hospice providing end-of-life comfort.

Palliative Care Emphasizes Quality of Life; Hospice Provides End-of-life Comfort

Palliative care is a medical specialty aimed at patients with a serious illness, focusing on symptom treatment and quality of life improvement. It can be provided alongside other therapies without the immediate prospect of death. In contrast, hospice is a subset of palliative care, typically reserved for the final months of life where curative treatments are no longer pursued. Palliative care, seen as "whole person care," addresses a variety of needs from pain management to emotional support. Bridget Sumser stresses that quality of life is defined by the individual and that palliative care is designed to meet each person's unique needs.

Misconceptions Cause Patients and Families to Delay or Avoid Palliative and Hospice Care

Misconceptions about palliative care often cause patients and families to delay seeking services. Many equate it with giving up on treatment or preparing for imminent death. However, once the true nature of palliative care is understood, its value is typically recognized. BJ Miller underlines the importance of changing terms like "DNR" to "A&D" to focus on the care provided rather than what is not being done. These misunderstandings could contribute to underutilization of palliative and hospice care, despite their valuable focus on the quality of life.

Systemic Challenges In Providing Comprehensive End-of-life Support

Hospice Care at Home Lacks Support, Burdening Families

Home hospice care, where expert teams offer intermittent support, places a significant burden on families due to the minimal availability of full-time in-home support and the costliness of out-of-pocket care. Many patients have a preference to die at home, but the reality of care at home can be burdensome and may lead to family burnout.

Healthcare Lacks Early Discussions on Mortality and Dying Preferences

There's a critical opportunity for earlier engagement around mortality conversations that is often missed in the healthcare system. BJ Miller mentions a movement to introduce th ...

The discussion with BJ Miller and Bridget Sumser focuses on the nature of suffering and the importance of emotional and spiritual awareness in facing death.

Suffering Goes Beyond Just Physical Pain

The conversation highlights that suffering encompasses much more than physical discomfort.

Suffering Can Threaten Identity, Self, and Reality, Even With Managed Physical Pain

BJ Miller suggests that modern life has potentially induced more awareness of pain by providing solutions for discomfort, contrasting this to the past when people may have lived closer to pain and death. Sumser touches on the emotional and existential challenges that patients face when ill, not just physical pain. Suffering threatens one's identity and sense of reality. This suffering can stem from various sources, such as delirium or the mourning of the impending loss of life, which impacts one’s sense of self. Sumser discusses patients' ability to adapt, even in dire circumstances like Alzheimer's, suggesting that outcomes may not be as dreadful as anticipated.

Crucial Aspects: Emotional, Existential, and Spiritual Wellbeing

The importance of emotional and relational experiences at the end of life, especially for spouses or care partners, is emphasized. Miller notes the adaptability of younger individuals to their impending death—a reflection of how suffering impacts self and expectations. The role of palliative care in managing symptoms is acknowledged, yet Sumser and Miller indicate that suffering involves more than symptom relief; it includes emotional, existential, and spiritual dimensions.

Cultivate Awareness and Acceptance to Face Death With Clarity

A deeper understanding and acceptance of one's condition can help ease the end-of-life transition.

Self-Reflection and Confronting Fears, Regrets, and Beliefs Empower More Peaceful Death

Sumser and Miller suggest that Western individualistic approaches to suffering might be in conflict with a wider perspective that includes the family or support system. Sumser describes the ability to address suffering related to patients' spiritual and existential worries once physical symptoms are managed. Sumser and Miller see the "real work" in care to begin once physical comfort allows for the addressing of emotional, existential, and spiritual needs. They argue that this deeper work drastically influences the experience of suffering. Sumser speaks about the value of staying curious and receptive, emphasizing the development of self-reflection and awareness to face reality and fears. They recommend confronting one’s fears, regrets, and beliefs to allow for a more peaceful death.

Forgiveness, Connection, and Embracing Uncertainty Ease End-of-life Transition

Sumser and Miller discuss the importance of connection to self, environment, and others as v ...

BJ Miller, Bridget Sumser, and Peter Attia discuss end-of-life regrets, life lessons, and how facing mortality changes perspectives on what's important.

Dying Regrets Rooted In Unfulfilled Needs

The conversation reveals that common regrets and insights from the dying focus on emotional fulfilment rather than unaccomplished tasks.

Regrets Stem From Not Being True to Oneself or Relationships, Not Unaccomplished Tasks

BJ Miller states that common regrets shared by dying people often pertain to not allowing themselves to feel or be true to what they felt. These regrets are due to a separation between themselves and their true feelings or between themselves and loved ones, often due to shame. Miller observes that acknowledgments of feelings towards the end can defang fear and allow for reconciliation.

Dying Often Regret Not Expressing Love, Seeking Forgiveness, or Reconciling

The insights from those nearing the end of life include regrets over not expressing love or seeking forgiveness. Miller suggests that hindsight magnifies the artificial wedges placed between individuals and others, highlighting missed opportunities for connection and reconciliation. Emphasizing the importance of emotional expressions like love, forgiveness, and gratitude, Miller indicates these sentiments transcend cultural differences and remain significant for those facing mortality.

Life Lessons From the Dying

Dying patients offer profound insights about embracing uncertainty and prioritizing emotional, spiritual, and relational aspects over material accomplishments.

Embracing Mortality and Uncertainty Frees People to Be Present and Honest

By embracing mortality and accepting the uncertainties of life, people can become present and honest. BJ Miller’s near-death experience taught him the importance of being in the moment. Similarly, Bridget Sumser stresses the significance of focusing on valuable experiences rather than avoiding unwanted interventions. Sumser speaks about adapting one's expectations under new circumstances to find satisfaction, highlighting that meaning can be found in simple experiences, like observing the moon from one's bed.

Dying Clarifies Focus on Emotional, Spiritual, and Relational Growth Over Material Accomplishments

Miller and Sumser both emphasize that dying brings into focus the importance of emotional, spiritual, and relational concerns. For instance, in crises, patients often prioritize being emotionally present and maintaining relationships, such as fulfilling parental roles, over material achievements. Conversations about death guide individuals to focus on reconciliation and emotional experiences, and not causing suffering. Principles from Buddhism around meditation and peace ...