Why Some People Don’t Die in Peace

(Previously published in the Huffington Post)

Throughout my career as a doctor working with patients in hospitals, nursing homes and hospices I have had the opportunity to witness the dying process on many occasions. I have learned that even though the outcome of this process is always the same—the death of the physical body—there are many different ways to die.

In fact, each individual has a unique experience at the end of life. For some patients death is a welcome ending to a life well-lived, for others death is reluctantly accepted even though they don’t feel ready to let go of life, and some approach death kicking and screaming all the way. They “rage against the dying of the light” as observed by poet Dylan Thomas in a poem he wrote for his dying father.

Though I have seen that patients receiving hospice care often die with greater comfort than those in the hospital, there are still people who struggle all the way to their last breath, even when they are surrounded by loved ones at home. What makes the difference? Why are some people not able to be at peace when they die? Here are some of my observations from years of hospice work and my recommendations for ensuring that you have a peaceful death:

They haven’t thought about the end of life

We live in a society where death is still a taboo subject. Many people go through life without consciously considering the fact that they will die one day and are shocked when they receive the news that death is approaching. Since they’ve never thought about death they have no idea what type of care they would like to receive at the end of life and find it difficult to make clear choices for themselves while dealing with the stress and fear caused by a terminal diagnosis.

Recommendation #1: Begin to think about the reality that every living thing on this planet eventually dies and then spend time contemplating the fact that you too will die one day. The Bhutanese people have a practice of thinking about death 5 times a day and have been named “the happiest people” on earth. So make a point of thinking of death on a regular basis, perhaps reading books and watching films to help you get more comfortable with the idea of death.

They haven’t put their wishes in writing

Those who haven’t thought about death also have not made plans for the end of life or completed an advance directive. A recent study has shown that two out of three Americans have NOT put their end-of-life wishes in writing, which means they are more likely to receive expensive and unwanted care during their last days. According to a survey by the CDC, most patients do not want to die in a hospital attached to machines, but that is only possible if they have made the decision ahead of time and completed an advance directive.

Recommendation #2: Start by completing your own paperwork now for the end of life, such as a living will, estate plan, and funeral plan. Think through the options for care that might be available to you and formulate your own opinions—what is important to you? What are your wishes for your last days on earth?

They haven’t talked to their loved ones about their preferences

During a healthcare crisis many patients are unable to speak up for themselves about their end-of-life choices. If family members don’t know the patient’s wishes they will find it difficult to make appropriate decisions for their loved one on a moment’s notice. In my experience, uninformed family members are more likely to defer to medical providers when end-of-life decisions must be made and are also likely to experience guilt and conflict with one another over those decisions.

Recommendation #3: Once you’ve decided what you want for yourself at the end of life it is vitally important that you have conversations with everyone in your life that may be involved in making decisions for you. The more you talk about it the more you will create peace for yourself and for your loved ones when the time comes.

They have been unhappy all their lives

There is a saying in hospice that

people die the way they’ve lived.

I have observed that patients who have held onto bitterness and disappointment about life tend to be unhappy during the dying process as well. Since they had never learned how to be at peace with the circumstances of life, when death is near they remain angry and inconsolable. Woody Allen wrote for the movie Annie Hall that life is “full of loneliness, and misery, and suffering, and unhappiness, and it’s all over much too quickly.” This epitomizes the attitude of the unhappy patient at the end of life, who hated every moment of being alive but is now furious that it is coming to an end.

Recommendation #4: The antidote to this type of misery is to learn to find happiness within yourself long before life reaches its end. Each of us is responsible for creating our own joy in life, even if life hasn’t turned out as we have hoped. Conduct your own “experiment” and figure out what makes you happy—then cultivate those things in your daily life and you will look back one day to find that you have led a life filled with joy.

They are holding on to old regrets and resentments

Many of my dying patients have been ravaged by feelings of guilt and remorse over events of the past. They either have felt a deep need to make amends for some previous action of their own or they have been burning inside with resentment toward another person. Those who have not found their way to forgiveness have remained in this painful state of guilt and blame until their last breath.

Recommendation #5: It is never too early to start working on letting go of old wounds so that you can avoid the overwhelming negativity of resentment at the end of life. Develop your own daily practice of forgiveness and you will find much more peace in your life now, as well as during your last days.

They feel entitled to a different outcome

Some of my patients have been angry about the fact that they were dying because they spent much of their lives doing things they believed would “prevent” them from dying. They devoted themselves to a restrictive diet or intense workout plan or even strict religious practices in order to live life “the right way” and avoid something “bad” from happening to them. When they ultimately had to face the fact that they were going to die anyway they felt cheated and betrayed. They had fallen for a false belief that their healthy habits would somehow entitle them to avoid death.

Recommendation #6: It is important to come to terms with death, and your fear of it, earlier in life so that you don’t waste time and energy trying to prevent what is inevitable. Develop a practice of thinking about death as a necessary part of the life cycle and something not to be feared, but to be respected. Journaling, prayer and meditation can be helpful tools as long as they focus on the reality of death and are not serving as bargaining chips in a futile attempt to avoid death.

They rely on the medical system to make choices for them

Those patients who have avoided thinking about death generally have also not taken time to educate themselves about their own health issues. Without knowledge and information as a tool to guide decisions, they are disempowered when they must engage with the medical system. They don’t know what questions to ask or what alternatives to explore so they simply place all decision-making in the hands of their care providers. These patients may end up with more treatment than they want and encounter more suffering than necessary because they didn’t have the confidence and information they needed to help determine their own course.

Recommendation #7: While doctors are well-educated about disease and treatment modalities, they know very little about you, your life path and what options might be best for you. When you receive a chronic or terminal diagnosis it is your responsibility to learn as much as you can about your options by asking questions, reading and studying, and requesting second opinions. You are the only expert on the subject of “you” so don’t give up your power to another person, no matter how impressed you are with their credentials.

In summary, by looking at why some people don’t die in peace we have seen what is necessary in order to have a peaceful death. Being consciously aware of your mortality, working on your past issues, making plans and completing paperwork for the end of life, communicating with loved ones, and empowering yourself with knowledge are all important steps toward an end of life that offers comfort rather than chaos. But it requires work and dedication on your part to prepare now for what will be coming in the future.

Of course there are other reasons why some people don’t die in peace: they may have pain and other symptoms that haven’t been managed well, they may be alone and have no one to comfort them, they may simply be overwhelmed by the hand that life has dealt to them. But these are issues that may be addressed by finding support from hospice or palliative care workers, if that type of care is available (and reliable) in the community, though there are reports that hospice staffs are stretched too thin in some areas and care at times falls short of what it should be.

But you can improve your own chances of getting good end-of-life care by doing your own inner work, becoming an advocate for hospice and palliative care in your community, holding those organizations accountable to best-practice standards, and supporting causes that help people find peace in their lives. It’s never too early to start!


5 Simple Rituals to Enhance a Grief Travel Experience

If you are thinking of traveling to help process your grief, you might want to consider adding a ritual to your experience to increase the benefits you receive. Rituals have the power to open our hearts, even in the midst of pain, to opportunities for healing and release. This is why we hold funerals and memorial services for our departed loved ones, to help us express our pain and find solace in sharing it with others.

The idea behind a ritual is to create a safe space where we can explore our grief and let go of what no longer serves us. We do not let go of our loved one or our memories through a grief ritual–those remain intact as a pure expression of our love. But the ritual ceremony allows us to release the negative emotions that have become attached to our grief, like anger, blame, resentment, shame, and guilt. Letting go of these destructive feelings allows more room for love and peace to expand.

Creating a meaningful ritual while you are traveling requires some resourcefulness, since you won’t be able to bring along a lot of ceremonial tools and supplies. But you can design your own simple activity for acknowledging grief by utilizing the special places and natural objects that already exist wherever you are traveling.

For a nature-based ritual for grief, spend time outdoors wherever your travel takes you. Even in a city you should be able to find a park or garden where you can wander and connect with nature. Also look for sacred spaces in the area, like chapels, cathedrals or churches. Many are open during the day with free entry to anyone and they can provide a quiet and inspirational place for your little ceremony.

Here are some ideas for simple rituals you can observe during your journey:

Filling the stone

Walk slowly and mindfully somewhere outdoors, like a garden, beach, hiking trail, or park. As you walk, pay attention to everything around you and search for special objects that capture your attention such as stones, shells or pinecones.

Hold the stone or shell in your hands and meditate on the emotion you would like to release during your ritual. Envision pouring your anger or guilt into the object which has infinite capacity to carry everything you need to release. Carry the stone or shell with you for as long as you like until it  feels right to let it go. Then put it in a special place and say a prayer for your  peace and healing as you leave it behind.

I collect heart-shaped stones when I hike or travel and have found them in many places. Some stones I carry with me as reminders of my journey and place in my forgiveness garden at home; others I leave behind on my travels, perhaps at the base of a tree or on a large branch.

Gone with the wind

While you are out in nature on your grief journey you can gather dandelions, small flowers, leaves or tufts of grass to use in your ritual. Contemplate how they represent the impermanence of life, the fleeting nature of everything that lives. You might want to assemble them into a design or shape or just hold them in your hands. Whisper a prayer or a wish for your loved one or yourself into the items you have gathered, then scatter them one-by-one in the breeze or blow on the seeds of a dandelion so they are carried far away by the wind.

This ritual symbolizes the fleeting nature of life–here one minute and gone in the next–and reminds us to make the most of each moment we are given.

 Light in the darkness

Lighting a candle or a small fire is one of the most potent rituals you can perform in a spiritual setting. Candles are part of special ceremonies in every religion and signify hope in the midst of despair and the ever-present light that shines for us in times of darkness.

I love to light large sanctuary candles that burn constantly for 7-10 days during special rituals in my home, but they are not practical for travel. You can easily travel with a few small tea lights in your bag to use for a lighting ceremony or fire ritual, where you burn small pieces of paper with what you want to release written on them.

Since some hotels and establishments don’t allow open flames you can also bring along flameless, battery-operated tea lights to achieve the effect of lighting a candle while you meditate or pray.

At many churches and cathedrals you can donate a few coins and light a special prayer candle. This has been a powerful ritual for me during many of my travels through Europe, which often include visits to religious shrines.

Letting go and receiving

If you are near a river or stream find a bridge that spans the flow of water for a simple but powerful ritual. First stand at the middle of the bridge facing downstream. As you watch the water flow from under the bridge and away from you, imagine pouring everything that no longer serves you into the water and see it be carried off down the stream.

When you have finished letting go of what you need to leave behind, turn around to face the water flowing toward you. Imagine love and light rushing to you, filling all of the new space you have created within. Feel the power of the water as it roars toward you and washes away all that you have released. Receive all of the goodness and peace that is now coming your way.

I often gather flower petals, leaves and sticks and “fill” them with whatever I need to release. Then I toss them into the water flowing downstream so I can watch as they are physically carried away from me.

Mindful tea ceremony

The Japanese have long perfected the art of preparing and serving tea in a  tradition that dates back 1,000 years. They pay special attention to every aspect of the ritual including decorating the table with flowers, making special food, choosing the tea, and using the right utensils and dishes.

You can create your own tea-drinking ritual as an act of releasing grief by being mindful about each step of the process. The Japanese emphasize four qualities during their ceremonies: harmony (ensuring that even the utensils coordinate with the surroundings), respect (approaching the ceremony with humility and care), purity (leaving behind all thoughts and worries), and tranquility, which occurs as the result of completing the ceremony.

For you own personal ritual use great care and mindful intention as you prepare your tea, serve it in a special cup or glass if available, and sip it slowly throughout a quiet session of meditation or prayer.

I once sought refuge in a tea shop during a torrential rainstorm while traveling in Florence, Italy. The ritual I had planned for the day had to be abandoned because of the weather, but the little tearoom in the back of the shop gave me an opportunity to have a special tea ceremony instead. I dedicated it to my Mom who would have loved sharing tea with me that day!

These are just a few suggestions for simple rituals you can perform during your grief travel experience. You can easily create your own ceremonies by paying attention to what is available to you wherever you go and staying open to your intuition.

Whatever you choose to do, your travels will be far more meaningful and transformational because of the special time and attention you give to creating simple rituals for your grief. May you experience tranquility and peace at the end of your journey.