Pam Kircher: The Lessons of Death and Dying
Pam Kircher is a family physician and hospice doctor who served as director of Integrative Medicine at Mercy Medical Center in Durango, Colorado, from 2001 to 2006. She speaks nationally on integrating complementary medicine into the conventional medical setting. She is also a childhood near-death experiencer and, in 1995, wrote Love is the Link: A Hospice Doctor Shares her Experience of Near-death and Dying. Kircher was co-facilitator for “Living with Mortality: How Our Experiences Change Us,” the 5th Annual Ikeda Forum for Intercultural Dialogue, held September 20, 2008. Two days after the event, the Center’s Mitch Bogen sat down with Kircher to reflect on the Forum and to talk about the benefits of a more humanized approach to healthcare and the process of dying.
Valuing Spaciousness of Time
You have written that for people who have been transformed by their experience of being with loved ones who are dying, the change in their lives is often toward greater balance, more spaciousness of time, and an emphasis on peaceful, loving relationships.
What I mean by greater balance in life, and greater spaciousness – they kind of go together – is that I see America and the American culture as being out of balance. We are very fast and very busy doing little of true value. Running around doing all sorts of stuff, we have no spaciousness in our lives. We’re totally booked. And at the end of the day, what have we accomplished? Just by being with a loved one who is dying, of necessity, you cannot just do, do, do, like you normally might. There’s no way you could be present for them. And what we find when being fully present is that the spaces in the talking are when the depth arises. Amidst the usual barrage of words and all the “busy-ness,” true depth never happens. That’s what I mean by the value of balance and spaciousness.
Not all relationships are peaceful and loving, of course, but when peaceful, loving relationships occur, I think we get an addiction to having them. That’s what we want. And so we begin to look more and more for it: How can we make it happen? Because there isn’t anything better than the real feeling of a heart connection with another person. So anytime we have cared for a loved one and have experienced that feeling of peaceful, loving connection, we are reminded of the other relationships in our lives, and we ask ourselves: How can these also be peaceful? And what keeps them from being that way?
Creating the Conditions for Meaningful Death
You have also written that before the start of hospice, in the late ’60s to early ’70s, most people receiving medical care at the end of life died alone in ICUs, with just fifteen-minute visits from loved ones, once or twice per day. What was the impact of that practice?
I think that when you only see a dying loved one for fifteen minutes once or twice per day, you’re not likely to catch them in that spacious moment we talked about. You’re capturing just a little glimpse of the 24 hours. And most of the time, the person is not present in any deep way during that time. And hospital staff also told family members: Don’t upset them! So that meant don’t talk about anything that really matters. Don’t talk about forgiveness. Don’t talk about feelings. Don’t talk about what’s going to happen next – like death! Don’t mention that word! So you go and talk about the weather. And frankly, they don’t care about the weather. They feel you’ve come in and been completely out of synch with them, not connected. That does not feel good.
Real connection could happen, but it would have been almost a miracle, if, in that little fifteen-minute segment, something deep and meaningful did occur. Plus, in the ICU, minimal thought was given to quality of life; it was about length of life. And it was about getting the person out of ICU. So any extreme measure was taken to keep a person alive, and those measures often resulted in more pain. And they gave less pain medication than we do now. I know from being with people in pain that when the pain is so loud in your life that all you feel is the pain, it’s very hard to do anything deep or emotional like forgiveness. You cannot think. Honestly, the way death was, people didn’t have a chance to say goodbye.
Even hospitals now are closer to hospice.
The hospital experience has learned from hospice. The trend in hospitals now is for it to be a patient’s right to be as comfortable as they want to be and to receive proper pain management. Pain management has really benefited from what doctors have learned in the hospice setting, namely that more pain medication can actually be better and that it is helpful for family members to be there more often. So even ICUs let people visit a lot more than they did in the late ’60s.
Good pain management and good symptom management are important so that the “work” of dying can actually be done. For example, a person can do their “life review” – looking back and seeing what had meaning in their life and what still needs to be done for them to have a peaceful death. They can do that. They can think about things and have the talks they need to have. And there is also that spaciousness of time, without the expectation that someone will be with you for only fifteen minutes. People can sit together.
And just being together can be so important.
Exactly. So often you don’t have to say a darn thing. I remember this comment from one of the other Ikeda Forum panelists, made during our Friday seminar session: “I thought I had all of this to say, and I realized that just being there and breathing with him was enough. Sitting there we knew we loved each other. We didn’t need to talk about what specifically needed to be forgiven.” It was all water under the bridge, truly washed away.
Some Lessons Learned
You recommend that we live our lives from the perspective of a person who expected to die next week.
And I actually do that. Every morning, or every evening before I go to bed, I do a quick check in and ask myself: Is there anything that happened today, if I never got a chance to resolve it, I would feel uncomfortable with? I like to go to bed each night with an absolutely clear state, so if something isn’t good, I think about how to clear it up.
You also invite each of us to write down what we are doing to bring about a simpler, gentler world for ourselves and others.
I recommend that whenever you really want to make a change in your life, write it down. Invest yourself in putting it down on paper. You can save it and pull it out in a week and ask: What have I done to achieve this? That’s more likely to make something happen than just thinking it. So if I really mean something, I write it down.
Does it foster hopefulness when people learn how to take small actions?
To say we’re going to change the whole world is so overwhelming. We just turn on the television set! But if you say that when something comes up that pushes my buttons today, I’m going to deal with that before I go to bed: That’s critical. I’m going to deal with my reaction to it. I’m not going to fix something “out there”; I’m going to fix something “in here.” I’m going to see it another way and become responsible not only for my actions and words, but also for my thoughts – because the actions and words come after the thoughts.
Reflecting on the Ikeda Forum
Which aspects of your work and experience did you choose to emphasize at the Ikeda Forum?
There were so many things I might have emphasized, but first of all, I wanted to communicate a sense of history, so that we could see how far we’ve come with the hospice movement. So often we’re not optimistic about things because we don’t see what has happened before. So I wanted to give that sense of hope and the sense that, yes, we’re in the middle of this revolution. We’re not starting it; it’s happening.
And in that story is not only the history of how we treat death and those who are dying; it’s also the story of how we are taking back responsibility for our own healthcare and all the related choices. We’re no longer laying ourselves on a table in front of a doctor and saying, “Fix me, I’m a car that’s out of whack.” We’re saying, “I’m feeling something in my body that doesn’t feel balanced, and I want you to give me your opinion on restoring that innate balance in my life.”
I call this the new paradigm in medicine. And this new paradigm includes a combination of conventional and complementary medicines. People are going to conventional doctors for consultations, but that’s not the only advice they receive.
What do you mean by complementary medicines?
Other kinds of body-mind medicine, like acupuncture and massage, homeopathy and herbs, and so on. We are drawing on the whole array of things that people have done over time to make themselves well. And now there is a greater emphasis on wholeness and wellness than on the disease process and getting rid of symptoms. We’re moving past just labeling the disease we have. We’re forcing the medical profession to no longer refer to “the diabetic in Room 4.” Now it’s Mr. Smith, who happens to have diabetes, in Room 4.
During the Ikeda Forum, you framed your remarks to participants as an invitation for them to consider and share their own wisdom around death. This reminded me of a key idea behind BRC’s entire exploration of this topic: to “invite death out of the shadows” – as Center founder Daisaku Ikeda phrased it in his 1993 Harvard lecture.
That’s a definite connection. I used his talk very much as the basis for formulating what I was going to say and how I wanted the day to go. I agree with Mr. Ikeda that now is the time for us to dialogue with one another about the things that matter most – and what is more powerful, more connecting, than death and how we are influenced by it?
Mr. Ikeda also said in that lecture that we would do well to recognize what he calls “the deeper continuity of life and death.” What is your perspective on this?
I’ll preface this by saying that I never insist that people believe that we live before birth and live after death. I don’t think that to live a life of deep meaning, you absolutely have to believe that. I certainly do believe it, but I don’t think it’s required, as we discussed earlier. One can have a lot of joy in life by simply being present in the moment and having the intention to be loving.
On the other hand, if you have that perspective, you get less caught up in what I would call the illusions of life – those things that seem so immediate in the moment but that have no meaning before you come to this world and will have no meaning when you leave. It helps you to take everything more lightly. Many people are able to live an easy, gentle life because of that wider perspective, but I think it’s possible for others to also live that kind of life, even if they don’t share my belief.
How would you connect the deeply personal reflections in the Ikeda Forum’s morning session with the call for positive social change in the afternoon? Can our personal experiences tell us something about our social challenges?
I think that as we experience those changes that result from being with people who are dying, we come to see what we really value. And what we value is relationships and some time for personal reflection and those things that have so little to do with status and success and material acquisitions. And we find that what we have to do to get these things becomes burdensome – who would want to spend 80 hours a week at work? That’s a great way to make a lot of money and move up the ladder and maybe even become a CEO of something, but the tradeoff is you miss the personal reflection, the relationships, and the time necessary for them, because relationships are not ready to simply turn on when you show up. You have to actually be there, to be present.
When we come to value relationships and the time needed to nurture them – and, I should add, when we create a society where some of us don’t have to hold down two jobs just to make ends meet – we’ll work fewer hours, we’ll do less running around, and we’ll hopefully even use less of the world’s resources. We will be better citizens of the world when we have more time to reflect on the fact that we are indeed citizens of the world, not citizens only of the United States.
And we will have more time to be of service to one another, without regard to whether it’s making us any money. The new criterion is not money but satisfaction at the end of the day – do I feel like I had a life of service today? And when I say “service,” I do so recognizing absolutely that always there are things to learn from one another and to give to one another. So it’s not just one person always giving and one person always taking. We Americans have things to learn from every single person in this world.
I want us to be not just givers. I want us all to be the ones who give and receive, and in the end you can’t tell which is happening. That’s the world I want to see, where we are true citizens and flowing with everyone else who lives in this world, not merely using all the resources of our world.
When we do this, we actually have the personal resources and collective resources to solve the problems that we have as humanity. And it is humanity that has the problems now, not just one person or one country.
