Death and Dying: Meaning's Relation With Impermanence

Being deemed with a terminal illness has many effects on the mind. Doing hospice care over the last year has provided me the experience in which I was able to witness these effects and have conversations with patients about death and their lives. I found that meaning is something that can dramatically change when someone is ultimately facing their impermanent nature. The experiences that I had doing hospice care over the last year has provided me insight into how and why these concepts of meaning change. Meaning is something that is an incredibly important aspect of the human condition. 

It is alarming how many people are not ready to die when it comes to be their time to die. I have been volunteering for hospice care over the last year in hopes to familiarize myself with the idea of dying. I have interviewed Mary Landberg and Denice Stone, two hospice care workers for this inquiry. Using my personal experience, and the many years of hospice work that these two accomplished women have provided, I will be discussing how the idea and application of meaning changes when one has a terminal illness . Deaths are classified into two categories; as  complicated or non-complicated. Character traits of a non-complicated death are peaceful, calm, your way, your time, and good ties with the family. The contrary being a complicated death, can have the traits of, being in pain, not peaceful, wasn't your time, lasted out longer than expected, complications with the family. According to Denice Stone, about 25% -30% of patients who first enter hospice care can be classified in the non-complicated category. Hospice care strives to, by the time the patients pass, to have a 100%  non-complicated death rate. There can be many factors that  play into someone being ready or not to die.

 Death is a taboo in our culture here in America. The treatment of death as a taboo, has many impacts on the inevitable dying process. Mary Landberg states that, “Most people don’t give death a thought until death is knocking at their bedroom door. It’s going to happen to all of us, but most are in denial about it.”  We treat it like a white elephant in the room, never wanting to take a look at the reality of our impermanence. One instance of  this taboo is from our funeral rituals and how we treat bodies as soon as the individual is deceased.  We place the body in a bag and then put it into the coffin, not wanting to see the grim reality that we all face. It can also be from the language that we use, afraid to use the “D” word; death. The fear that our culture creates and the way we treat it are completely different from other cultures around the world. The apparent dissociation from dying has grave impacts on the mystery and fear that individuals feel when they receive the diagnoses of a terminal illness. The fear and mystery of death, is heightened by how our culture perceives the dying process. Perceiving death as a terrifying process that must be avoided, as opposed to a natural occurrence,  influences people not to want to take a look at death itself. Individuals do not want to talk about death, see it, and ultimately do not want to experience it themselves. The negative cultural perception of death  made volunteering for hospice care an evermore intense experience.

 I decided to start doing hospice care in hopes to  better understand the process of death.  I wanted to see how people were dealing with the idea of impermanence in this world at the very least,  and how it affected their mentality. I started to do volunteer work in August 2014.   I completed a few days of training and that made me realize how uncomfortable I was with the idea of death. It was a completely foreign experience to talk about death and  its symptoms so casually in a room full of people. We learned how to approach depression and suicide in patients  that would lead us to believe they would be passing on soon, and how to spot the signs and exactly what to do in the case of depression or suicidal thoughts. After a few training sessions,  I was ‘ready’ to go out to a stranger's home and keep them company and hear what they wanted to say. I originally signed up to be a patient care volunteer.  My job was to run errands for the family or provide respite for the primary caregiver and  to allow them time for  themselves.   I would come over and keep the patient company and talk. However, my biggest role was simply to listen to the patient and hear what they needed to say. I had no ties to them, I was not a dear friend or family member that they had a connection with or concerns of judgment. My experience in doing the volunteer work was to be an unbiased listener to whatever they wanted to talk about.  My experience in doing hospice care made me confront what it’s like to watch someone die, and what they think about during this unfamiliar time in their life.

By the time someone contacts hospice care for their services, they have confronted the idea of impermanence to some extent. They seek services ranging from volunteers for company, medical services, photography sessions, life recording, pet care, errands, sitting vigils, almost anything to make their life easier. Yet, this is an incredibly intimate and unfamiliar time in the patient's life. I have done many tasks for hospice care, but the most important one I believe, was being a patient care volunteer. 

The first patient I ever spent more than a week with was classified as a complicated death. They were not okay with the idea of dying. I would go over to their house for four hours every week. The visits started out very casually, talking and drinking coffee, watching science fiction movies, and simply hanging out. We spent more and more time together becoming more comfortable. My service to listen to what they had to say started to be the utmost of importance to them, even when the visits became incredibly dark. I would hangout and listen to the stories that they wished to share with me. When this particular patent was labeled with a terminal illness, they realized they had not lived a life that they were proud of. Subscribing to the Christian faith at the end of their life,  they were convinced that they were going to Hell, and there was nothing I could do, nor could they do, that would change this. The conviction of going to Hell in the face of Christianity resonated with the idea of not being worthy. The visits started becoming more and more anxiety provoking for us both. Every week for me, it felt like the patient  was getting closer to the end, which to them was eternal suffering. At this point, our visits had ultimately stopped happening.  The experience with this patent left me in a dizzying state, making me more afraid of death than when I had started. Witnessing that it is indeed very possible to live a life that I have regretted and it is too late to fix. There is a lot going on with this experience, I believe that the application of meaning and how it can change when one realizes they are out of time was the root of their troubles.

The experience with my first patient really illuminated the idea that the application of meaning can change in dramatic ways when someone is confronted with death. It is indeed possible for one to realize on their deathbed that they have not lived the life that they wished they had. This is a terrifying feeling and one that will stay with me as a learning experience. This experience shows insight into the concept of meaning and how it changes when one becomes terminal. When talking with Denice Stone, about patients who first come to hospice care and are classified as a complicated death, there seems to be something missing in their life as opposed to someone who is not complicated. I believe that meaning is the underlying factor here.

Meaning is something that can be hard to determine for oneself. Truly contemplating impermanence at this stage in my work with hospice, I felt lost as to where to place my meaning in the world, knowing the possibility that it can completely change in the end when it seems to be the most important. If in the end, I will die, and quite possibly regret the life that I have lived, then what is the point of meaning?  I do not subscribe to any particular faith. The possibility felt a little too likely that I will find myself in similar shoes as my first patient. Living one life, only to wish I had led another when it became too late. How does one prevent this from happening in the first place? Meaning is something that many people struggle with. As Mary Landberg states, “People need their life to mean something.  They don’t understand what meaning is. They think it is a product of something. They need someone to tell them to be a missionary and save souls or something.” 

Socrates famously said, “The unexamined life is not worth living.”  Socrates spent his days walking around Athens and talking to its citizens about philosophy. He wanted the citizens of Athens to examine what they believed and why. Being deemed terminal, it seems that it forces one to examine the life they have lived thus far. It forces the individual into a state of reflection of how they have chosen to exist, as well as their values and why they choose to subscribe to some beliefs as opposed to others. Sometimes this forced reflection on their lives comes too late to apply Socrates’ wise words on the necessity and benefits of self reflection. They reflect on their  happiest moments, their saddest, what they are proud of, what they are not. In most cases, as discussed earlier, when people come to hospice care they are still classified as complicated. I believe that Socrates’ examination is one thing that could be missing in their lives. Socrates’ examination can provide an insight into the concept of meaning for the individual.  The important question being raised here is, “What does this say about the concept of meaning and how people view it throughout their lives?” In most cases, people are not ready to die when they first receive a terminal illness. When asking Mary Landberg, “Do you find that the ‘meaning’ of life changes when one becomes terminal?”  She answered’  “It certainly can, and often people don’t even think about the meaning of their life until they are given a terminal diagnosis. They ask a question like, ‘What was my life for?’ This is one of the most gratifying parts of my job,  as I get to help them find meaning. I have them tell me their stories so they can hear themselves out loud speaking about their accomplishments and experiences they may have forgotten or put on a back burner because they were so wrapped up in the mundane patterns of life.” 

There seems to be a sense of pressure that is applied to the patient to have the meaning of life figured out for themselves by the time they are terminal, or simply have it. This pressure can come from two sources: either within the individual, or from society. As opposed to someone in my situation, that is healthy and young, I still have time to figure it out for myself. I cannot help but think of the existentialists in this situation. Existentialism always flourished in times of great peril, whether it was on the battlefield, depressed and alone, being held prisoner, even just a stranger, they uphold that the world is intrinsically meaningless. The existentialists who use literature as their medium like to convey this realization when the end seems imminent,  a familiar situation in which the hospice patients find themselves. The world does not have meaning, it is up to them to supply this sense of meaning to it.  Individuals who have a drawn out death, that is to say reconcile with the label of a terminal illness have time to contemplate and reflect on their lives. Facing death in the near future can change an individual with this sense of reflection, heavily influences how they can conceive meaning. Experiences of this nature makes meaning ever more elusive to find. Part of the pressure that hospice patients feel is truly their impermanent nature, at least in their bodily forms. 

My next patient that I had was not willing/ready to die either. I did not get to spend very much time with them, yet it was reaffirming that it was more common than not, to never truly embrace impermanence as a part of the human condition. This unwillingness, no matter why, has effects on how we die. When asking Denice how common it is for a patient to hold onto the idea of permanence she responded, “I don't know how common it is, but I am thinking of all the individuals that I have seen, that letting go of permanence is when the true dying process occurs.” Accepting the fact that you will die, changes the dying process and makes it easier. The ability to accept death, hinges upon how we have lived our lives and how we feel about it, it seems. Continuing this conversation With Denice about accepting death and the influences it has on meaning, the differences between a complicated and non-complicated death came up again. She states that, “No, meaning can, but It doesn’t come right away, I’ve seen more people not want to talk about it. The people who don’t want to talk about it, tend to have the non-complicated death. The individuals who have already lived meaningfully, and once there they are done living for meaning.”

Meaning plays a crucial role with impermanence. Meaning by nature is a subjective value, and it is my power to place it how I choose. The action of applying meaning is one of the most important decisions that anyone will ever make. Putting it in the right places will make death easier, but putting it in the wrong place could make death tragic. Now, the question  should naturally arise,  “Where does one place their meaning?” There are many answers to this question.  Mary Landberg says that, “A primary regret of the dying is that they didn’t take the time to create happy memories for the people they are leaving behind.” This has been a huge shift for me. Mary continues, “ I have been integrating the “live while you are alive” mindset by traveling with my daughters and taking more adventures. My life feels more meaningful as a result. But, I am also more in debt, which has it’s own meaning.” This is to say, stop putting off adventures, create memories while you are alive. Having conversations with people your own age that are terminal, because they woke up with a strange  pain  and now they have a terminal illness, gives you this sense of needing to live before it’s too late. Stop saving for your retirement, don’t be afraid to take a trip to Paris. When talking with Denice Stone about what lesson she has learned from doing hospice work she responded with, “Love, it’s not even about unconditional love, it’s truly non-judgmental, just allowing.” What I find to be interesting is that both of these responses display that work in hospice makes us examine how we live our lives and our character traits. 

The goal and method of the Nicomachean ethics comes to mind at this point in self examination and what I have learned from hospice care. Aristotle wrote the Nichomachean ethics for his son, the book is a guide to live a good life and also centers around the idea of happiness. Aristotle's method was to talk to people and examine them, to learn what the good life entailed. This process is similar to the experiences that I have had, as well as Denice and Mary. We have talked with patients who are terminally ill and have learned from their experiences.  The Nicomachean ethics focuses on the individual's character and how they choose to live their life. The good life starts out in action for Aristotle, one must live well and do well. The good life for him, defined happiness in practical terms for the individual. The action can come in many different forms of action, the gardener, musician, philosopher, any action really. The patients that I have talked to that have had non-complicated deaths talk about their work and the life that they have lived. I helped with the recording program for an individual that lived to be over 100 years old. The recording program is for the families of the patient, we would go over to the patient's house with a set of questions and record their answers. We would either give them to the families on a flash drive or upload them online for free. The stories for this individual were about the time that he had spent working. He was a construction worker for his entire life, and did his job well, doing this line of work for over 70 years. He would talk about all the schools he had built around the area where I have grown up with a sense of pride in his modest work. The sense of life lived through work and doing it well, is one aspect of what Aristotle is talking about when prescribing happiness. 

Meaning, in the end, is always going to be someone's choice to apply how they choose. The regrets of the dying are focused on the idea of misplacing their meaning, or wishing that they had realized that this was their choice in the first place. What I have learned from hospice care is that meaning comes in many forms. For some,  it is the work they have done throughout their lives, the connections they have made, what they leave behind, their pets, even things I could never find meaning. What is important is the contemplation of meaning. The ones who truly are ready to embrace impermanence, seem to have found meaning, and in the end, have a non-complicated death.