Good Life to Good Death

After a relatively good life of more than 12.5 years, my notebook’s motherboard burned out.  I responded in Kubler-Ross model: denial, anger, bargaining, depression and then acceptance.  Since a new motherboard was no longer available, I ordered a new laptop during a Cyber Monday sale. Then I researched how to properly dispose of my old notebook, which is considered hazardous waste. 

I also considered how to dispose of my body (after death) in an environmentally responsible way.  According to TED Fellow and artist Jae Rhim Lee, our bodies accumulate a lot of toxins that can be released into the environment during burial or cremation, so she has proposed an Infinity mushroom burial suit to remediate toxins in the soil during decomposition of our dead bodies and transfer nutrients back to the environment.

Last month, I joined a standing-room only crowd of deathlings to meet Ask a Mortician’s Caitlin Doughty, who was promoting her latest book, From Here to Eternity: Traveling the World to Find the Good Death, at Green Apple Books. Growing up in sunny Hawaii, Caitlin became obsessed with death after the trauma of witnessing a girl fall (presumably to death) from a height in a shopping mall.  After college, Caitlin worked in an Oakland crematory, completed training to become a licensed mortician, founded The Order of the Good Death (to promote real talk about death and dying) and Undertaking LA (alternative funeral service that empowers people to have a closer relationship with death and the funeral process).

In California, the legal options and costs for disposing our bodies are:

• Burial: $7,000
• Cremation: $700-$1,200
• Scientific donation: no cost; see UCSF Willed Body Program 

In the U.S., the cremation rate recently surpassed the burial rate. According to Caitlin, cremation is not eco-friendly: embalming with toxic formaldehyde-based chemicals is often done even when a body is going to be cremated, and each cremation uses natural gas equivalent of a 500-mile car trip, requiring 28 gallons of fuel and effectively turning a body into air pollution! Dead bodies donated to UCSF and Stanford are ultimately cremated.

In her TED Talk, “A burial practice that nourishes the planet,” Caitlin advocated for access to more eco-friendly burial options:

• Recomposting:  based on livestock composting, architect Katrina Spade of Urban Death has proposed adding wood chips (carbon) to dead bodies (nitrogen) for decomposition by bacteria within 4 to 6 weeks, to create nutrient-rich humus to nourish our planet.
• Conservation burial: natural burial, aka green burial, using biodegradable materials (linen shroud, cardboard box) for return to nature.

Green burials are not new, but really a return to practices prior to the mid-19^th century (during the Civil War, embalming came into practice for shipping bodies over long distances) and customary for Jewish and Muslim burials.

Green burials are consistent with Zero Waste, adopted by California in 2002, and San Francisco has adopted to go Zero Waste by 2020, yet the nearest green burial option for its deceased residents is Fernwood Cemetery in Mill Valley (14 miles north of San Francisco).  [Since 1900, burials within San Francisco (land thought to be too valuable for the dead) have been prohibited, so most deceased residents are interred in Colma, located about 10 miles south of San Francisco and incorporated for housing the dead.]

“California has a particular significance in the modern history of death. In 1963, Golden State resident Jessica Mitford published her seminal exposé of the funeral industry, The American Way of Death. That same year, the Catholic Church approved cremation as an acceptable form of body disposal, and Southern California quickly became the capital of what Doughty describes as "the direct cremation revolution". Today, Northern California is at the heart of the "alternative death industry", which advocates eco-friendly, coffin-free home burials.”—Tim Walker, “Death becomes her: Meet the very modern mortician who champions ‘cool’ burials,” Independent (May 24, 2013) 

Jewish Community Center of San Francisco’s 3^rd Annual Embracing the Journey: End of Life Resource Fair was an opportunity to indulge in advance planning research.

Fair attendees were welcomed with Before I die, a community art project that invited people to reflect on their lives and share their personal aspirations in public.  It was originally created by artist Candy Chang on an abandoned house in New Orleans after she lost someone she loved.  Today there are over 2,000 walls around the world.  

At JCCSF’s Before I die, I want to … “go to Antarctica” was mentioned several times.  Most people sought experiences in travel (hike in Italy, return to Romania, gaze upon the Northern Lights, live on another planet), physical activity (skateboard, dance on a table again, skydive), and creativity (write a book, sing my songs).  There were few explicit altruistic experiences (be kinder to more people, make the world a little better as a first responder) that might be more common with people who have survived near-death experiences.  NYU’s Sam Parnia, MD, who has conducted research on consciousness after clinical death of people who survived cardiac arrest, made this observation to LiveScience: "What tends to happen is that people who've had these very profound experiences may come back positively transformed — they become more altruistic, more engaged with helping others. They find a new meaning to life having had an encounter with death." 

EOL Resource Fair offered a wealth of information, especially colorful informational brochures from Bay Area Funeral Consumers Association (BA-FCA), a local affiliate of Funeral Consumers Alliance, a national non-profit dedicated to protecting the right to choose meaningful, dignified, affordable death care.  Its Fall 2017 In Touch newsletter featured an interesting article about Alkaline Hydrolysis (AH), aka “water cremation” that will go into effect July 1, 2020, in California. AH is a process using a high pH (alkaline) solution to dissolve soft parts of the body, leaving only bones to be crushed and returned in the same way as cremation ashes, while the liquid is sent to a water treatment plant or facility where it can be used to generate energy.  While less polluting than conventional burial and cremation, AH uses about 285 gallons of water per cycle.

Hello to Nate Hinerman, co-Chair of San Francisco End-of-Life Network and my former SFSU Gerontology Professor who taught Death and Dying course!

Final Footprint, founded by Jane Hillhouse, offers biodegradable caskets made of wicker, bamboo, willow, etc.   

I attempted to attend overlapping afternoon sessions:

Stopped by to pick-up publications from Rebecca Sudore, MD, who presented Advance Care Planning Seminar & PREPARE Workshop (1-3 pm) covering 5 steps:

1. Choose a medical decision maker – who will ask doctors questions & respect your wishes
2. Decide what matters most in life – what brings you quality of life?
3. Choose flexibility for your decision maker – if something else is better for you at that time
4. Tell others about your medical wishes – document on advance directive form
5. Ask doctors the right questions – benefits, risks, options, what your life will be like after treatment; and make sure you understand

Stopped by to say hello to Deb Fox, Esq., former Board member of Legal Assistance to the Elderly, who presented, Getting Your Ducks in a Row Before You Go (1:30-2:30 pm).  Ask yourself this "ducklist":

• Do you have a trusted person(s) or organization to help?
• Durable financial power of attorney?
• Advance health care directive?
• Last will & testament?
• Revocable trust? Fully funded?
• Beneficiary designations for retirement accounts, annuities, life insurance policies, pensions?
• Passwords for online accounts?
• Plan for companion animals?

Attended talk (1:30-2:30 pm) based on new book, Life After the Diagnosis: Expert Advice for Living Well with Serious Illness for Patients and Caregivers, by Steven Z. Pantilat, MD of UCSF Palliative Care Service.  He noted that we live longer with serious illness, and death rate remains 100%.  He considered 3 myths v. truths:

1. You have to choose between quality and quantity of life v. You can have both with palliative care; 15% of people who receive hospice “graduate” (get better or stabilize).
2. Talk about what is really going on will destroy hope v. Talking about hope encourages it; ask golden questions (When you think about the future, what do you hope for? When you think about what lies ahead, what worries you the most?).
3. Goal is to have good death v. goal is to live a good life.  Remember people who made a difference in your life by caring, teaching something worthwhile and making you feel appreciated. 

Most important issues at EOL, according to California Healthcare Foundation (2011):

Making sure family not burdened financially by my care – 67%

Being comfortable and without pain – 66%

Being at peace spiritually – 61%

Making sure family not burdened by tough decisions about my care – 60%

Living as long as possible – 36%

Deathbed in Intensive Care Unit (ICU):  According to Dr. Pantilat, get better care at lower cost in home v. ICU. 

Cambridge University researchers found the chances of a good (comfortable) death are four times higher for the oldest old (aged 85+) in their own house or a care home, than those in a hospital ward. 

Chris Remedios, CFP, presented Preparing Financially for EOL

When I saw slide reading, “Peak financial capability around age 53,” I immediately thought yikes, should I continue working at a nonprofit? But then thought … Before I die, I want to do more advocacy to protect our safety net (Medicaid for long-term care, Medicare for hospice)! 

Opioid crisis update

Last month, President Trump declared the opioid crisis a public health emergency, with 140 Americans dying every day from opioid overdose.  Almost a third of Medicare patients—nearly 12 million people—were prescribed opioid painkillers by their physicians in 2016. Older adults are vulnerable when kidney and liver functions slow with age, increasing the time that drugs remain in their system and increasing the risk for overdose or addiction. 

This month, JAMA published research by Dr. Andrew Chang of Albany Medical Center, finding that opioids were no more effective in pain reduction than over-the-counter medications (ibuprofen-acetaminophen), after two hours in cases of arm or leg pain due to sprain, strain or fracture. 

The Opioid Epidemic in SF panel featured Paula Lum, MD, HIV PCP at UCSF; Terry Morris, Program Director at SF AIDS Foundation; Barry Zevin, MD, director of Street Medicine at SF DPH; Laura Thomas from Drug Policy Alliance; and Beth Stokes, Executive Director of Episcopal Community Services.  Take-aways:

• Opioid addiction is a brain disease; it’s biological, and partly genetics. Stop placing blame on people with substance use disorders, and address the issue as an illness.  
• Some people use drugs to feel good, but many people use drugs to feel less bad (as a coping mechanism).
• Rather than calling someone an addict, use the term “opioid use disorder.” Language matters to reduce stigma so people are more willing to help and seek help. 
• Buprenorphine and Methadone reduce drug use, but are tightly restricted in medical practice.
• SF DPH’s harm reduction approach to reduce overdoses seeks to create safe, supervised spaces for people who use drugs.
• Ask your pharmacist for Naloxone, the drug that reverses opioid use.
• Defend the Affordable Care Act, which has increased treatment access for people with substance use disorders.