Bucket list

Preparing to "kick the bucket"

At this month’s Jewish Community Center of San Francisco’s 2^nd Annual Embracing the Journey End of Life Resource Fair, attendees were presented with a bucket list kit—complete with bucket, pencil, mini-composition book and instructions to answer: What do you want to do before you “kick the bucket”?

I thought been there, done that.  Long before the Hollywood film The Bucket List (2007), I compiled a list of places to visit and pursued them all.  While I enjoyed the anonymity and stimulation from exposure to different cultural experiences during my world travels, however ephemeral, I felt world-weary after I became eligible to join Travelers Century Club.  Like Thomas Jefferson noted, travel makes one “wiser, but less happy.”  So I reduced my carbon footprint by staying home, content to put down roots while returning to my childhood pastime of gardening (being with nature).   

“…chasing bucket-list thrills ignores a deep psychological truth: You don’t need to make yourself happy in old age.  We get happier naturally as we grow older… The increased happiness doesn’t come through doing but simply through being.  It is the natural result of lower expectations and ambition, less emotional volatility, increased gratitude and acceptance and enhanced problem-solving skills.

In fact, the need for a bucket list goes against our deepest instincts as we age. Older brains are less influenced by novelty-seeking and more by conscientiousness; they are less impetuous and more emotionally stable.” 

– Marc E. Agronin, MD, geriatric psychiatrist, It's Time to Rethink the Bucket-List Retirement 

Stan Goldberg, cancer survivor, hospice volunteer and author of Lessons for the Living: Stories of Forgiveness, Gratitude, and Courage at the End of Life, presented, One Day to Live: What Would You Say and Do?

1. focus on journey – makes it easier to accept losses and prepare for death; start with one simple, enjoyable activity
2. ask for forgiveness – makes you more peaceful
3. offer forgiveness – begins healing
4. understand what/when you can’t forgive – work towards understanding
5. let go of what you can’t change
6. offer thanks for kindness shown – change relationship
7. complete unfinished business
8. create legacy – make a difference 

Therapeutic humor expert Allen Klein provided comic relief in his presentation, Seeing Demise Thru Humorous Eyes: How Cartoonists, Comedians and Cinematographers Help Us See Death as Less of a Grave Matter.   My favorites were clips from Woody Allen films like Hannah and Her Sisters (life affirmation after attempted suicide) and Love & Death (dance with death).

End of Life (EOL) Options (ways to "kick the bucket")

Matt Whitaker, Multi-State Implementation Manager at Compassion & Choices, provided an overview of authorized EOL options:

1. refuse treatment
2. discontinue treatment
3. hospice – “gold standard” for last 6 mos. covered by Medicare, but average utilization only 20 days
4. VSED (Voluntarily Stop Eating & Drinking) – death by dehydration
5. palliative sedation – induce coma
6. aid in dying – legal in 5 states, OR (since 1997), WA (2008), MT (2009), CA (2016) and CO (2017)

California’s End of Life Option Act requires self-ingestion of a lethal dose of 100 capsules of Seconal, produced by Valeant Pharmaceutical, at a cost of $4,000; in California, only 80% of private insurers and Medi-Cal cover this cost.  A 1997 federal law prohibits use of federal monies (Medicare, VA) to cover aid in dying costs. 

JFCS Seniors at Home hosted End of Life Option Act: Effects on our Practice panel presentation:

• Linda Blum, GNP, Palliative Care Coordinator at California Pacific Medical Center: shared two cases when patients were not able to exercise EOL Option due to short time frame of patient with untreatable gastrointestinal bleeding who died in hospice at home before he was able to manage 2 requests to doctor, and another patient with ALS who was not able to self-administer aid-in-dying drug; in both cases, it was “care as usual, the old way.”
• Maryellen Collamore, ASW, Oncology Clinical Social Worker at UCSF: talked about her role to provide educational materials on EOL Option and to conduct psychosocial assessment of patient (motivation for inquiry, understanding of diagnosis, social supports, defining quality of life, perception of dying process, exploring belief systems, etc.); patient also must obtain mental health evaluation by psychiatrist; easier to find consulting MD than to find MD who will actually prescribe aid-in-dying drug; patient’s initial inquiry opens door to conversation, and most patients go to hospice.
• Lael Duncan, MD, Medical Director at Coalition for Compassionate Care California: opined that access remains an issue, given the length of the process (patient makes 2 oral requests > 15 days apart, patient attestation 48 hours prior to ingestion) and few participating providers. She described lethal prescriptions—traditional high dose barbiturate (100 capsules of Seconal used in Oregon) dissolved in 4 oz. water; cocktail mixtures (opiates, benzos, cardiac meds); complications can arise if patient has difficulty swallowing, digestive issues, insufficient absorption; time to death depends on underlying disease process and patient’s physiology, but usually deep coma within 10-15 min. after ingestion.
• Redwing Keyssar, RN, Director of Palliative Care at JFCS Seniors at Home: shared two cases of patients who changed their minds about EOL due to different outlook and changed circumstances because pain and symptoms were better managed. 

Lonny Shavelson, MD, started Bay Area End of Life Options in Berkeley, to consult with physicians and patients who are deciding whether to participate in EOL Options Act. He sees writing the lethal prescription to a terminally ill patient as the last resort only after considering alternatives (hospice and palliative care approaches).  

Documenting life

At Rhoda Goldman Plaza, Gloria Hollander Lyon, who survived seven concentration camps during the Holocaust, read excerpts from her memoir, Mommy, What’s that Number on Your Arm? A-6374: failing Dr. Mengele’s inspection and then escaping the gas chamber by jumping off a truck at age 14; later living with a foster family in Sweden after liberation when she noticed she lost her sense of smell – perhaps her body’s defense mechanism to protect herself from the horrific stench of bodies burning in the gas chambers and crematoria; and then returning to visit Auschwitz in 1991 when she finally regained her sense of smell after 47 years. 

Addressing an intergenerational audience that included her son, Lyon said her father told her what is important: do not cry over what is lost if you have freedom for continued life, let it rest and start all over; those who survive are eager to tell the world that it’s worth surviving regardless of loss. 

Lisa Kokin’s Inventory, exhibited at From Generation to Generation: Inherited Memory and Contemporary Art at Contemporary Jewish Museum, is composed of over 1,000 pieces of objects representing the lives of those who endured the Holocaust.  Inventory was created in 1997 after the artist, whose own Jewish family left Europe before Hitler’s rise, visited Buchenwald concentration camp and confronted the piles of objects left behind.

At this month’s meeting of San Francisco Task Force on Hoarding, Carolyn Rodriguez, MD, PhD, Director of Stanford Hoarding Disorders Research Program, talked about her research combining Buried in Treasures (BIT) workshop support group with one-to-one home de-cluttering.  She viewed hoarders as “enthusiastic collectors” and talked about elevating ordinary objects into art by Marcel Duchamp’s Readymades and Andy Warhol’s Time Capsules.  She mentioned artist Song Dong’s Waste Not installation of over 10,000 everyday objects collected by his mother in their Beijing home over five decades that reflects on culture of frugality; in persuading his mother to make art out of her possessions, the artist showed respect while also improving the quality of home life by de-cluttering – more creative than the KonMari method! 

As in Roz Chast’s Can’t We Talk About Something More Pleasant? discussing hoarding and even the inevitable like end of life can be uncomfortable for some.  Yet, the wisdom of Ecclesiastes chapter 3 reminds us: “there is a time for everything … a time to be born and a time to die … all come from dust, and to dust all return.”

With Howard Levy, Executive Director at Legal Assistance to the Elderly (LAE) for 28 years until his retirement today, all discussions are possible! (Though professionally, Howard is probably not as candid as his high school classmate Pepper Schwartz, AARP’s Sex and Relationship Expert and author of the sizzling erotic memoir, Prime: Adventures and Advice on Sex, Love and the Sensual Years.)  At weekly case acceptance meetings deftly facilitated by Howard, all staff and volunteers present contributed to the lively, often passionate, discussions for each client intake after hearing the facts.  Occasionally tired of the faux (steamed, not authentically boiled) bagels brought in by Howard, staff and volunteers turned the weekly meetings into potluck affairs.  Howard and the mostly senior staff at LAE remind me of The Supremely Old, Supremely Sharp, Supreme Court, with their wit and crystallized intelligence, which gets better with age. 

Inspired to create my own art, here’s collage of Howard's greatest hits at LAE’s office and fundraising events!