Death Anxiety: Dani Chammas & Keri Brenner

Eric 00:11

Welcome to the GeriPal Podcast. This is Eric Widera.

Alex 00:12

This is Alex Smith.

Eric 00:13

And Alex, I think we have some returning guests with us today.

Alex 00:17

We are delighted to welcome back our psychiatrist and palliative care dynamic duo, Dani Chammas, who is a psychiatrist and palliative care doc at UCSF. Dani, welcome back to the GeriPal Podcast.

Dani 00:28

Thanks for having me.

Alex 00:29

And Keri Brenner, who’s a psychiatrist and palliative care doc at Stanford. Keri, welcome back to GeriPal.

Keri 00:34

Great to be here.

Eric 00:35

So I probably shouldn’t admit this because I know I have Dani on, and she’s going to quiz me if I say that I listened to one of her and Keri’s talk, but I did. HPM had a great talk about death anxiety. I thought, man, this is the first time I’ve ever actually been in a talk about death anxiety. So I…I love to hear kind of what it is, how we should be thinking about it. So welcome there to our Death Anxiety Podcast. Not to add some more anxiety into your lives, but before we jump into the topic, Dani, I think you have a song request.

Dani 01:09

Yes. Don’t Fear the Reaper by Blue Oyster.

Eric 01:14

Besides being perfect for this talk, any other reason why you chose this song?

Dani 01:21

Well, I mean, honestly, nothing says let’s talk about death like a classic rock anthem, but maybe the reaper has a lot to teach us. Maybe fear isn’t the only way to face it.

Eric 01:33

Okay.

Keri 01:34

Very deep. Lots of layers to that.

Alex 01:36

Good. Okay, here’s a little bit. And I’m putting my son Kai to work because he’s home for the summer from college. So if you’re listening on the audio only, you get Kai on guitar.

Alex 01:54

(singing)

Eric 02:33

Such a good song. Good choice, Dani.

Alex 02:36

Thank you. That was fun.

Eric 02:39

All right, Dani, let’s talk about fearing the reaper. Either one of you, like, what? What is death anxiety? How we are defining that for this podcast?

Keri 02:51

Yeah. Let’s dive in, Eric and Alex, with some definitions to start to ground us. Death anxiety is the psychological and existential distress that’s related to one’s own death, the process of dying or the prospect of non existence, or concerns about the afterlife. So death anxiety in that regard can be conscious or unconscious. It encompasses fears, apprehension, dread. At its core, it exists because we as human beings are uniquely aware that we are mortal beings. And that awareness is what sets the stage for death anxiety to emerge.

And I often think of psychiatrist Irvin Yalom, who’s here at Stanford, 93 years old now. He describes death anxiety as one of the four ultimate concerns of human existence. So the other concerns beyond that. The second is meaninglessness, that craving we have for purpose, loss of freedom, concerns about autonomy, responsibility for choices, and lastly, a sense of isolation or that existential loneliness. So the most salient feature of death anxiety is that it is truly universal to the human experience. It’s tempting for us to conceptualize it as something that’s just this circumscribed thing that only happens to patients who are seriously ill and that’s just erroneous in myopic.

Eric 04:14

So universal is a very strong statement because the longer I do medicine, the more I realize, like, nothing is universal like pain. Like we always think, oh, pain is universal. But no, like there are some people can’t feel pain. Like there’s. It’s such a diversity. I can imagine it’s. I think the word I heard on your. Your talk was ubiquitous. It’s common, but universal.

Dani 04:38

I’ll challenge you.

Eric 04:39

Yeah.

Dani 04:40

Name one human you know who isn’t going to die.

Eric 04:44

There is none, but pretty universal. But no, I know, I’m. Because quite honestly, what about like people.

Alex 04:54

Who are stoics or who are Buddhist monks?

Keri 04:59

Yes, we can definitely. I’m excited to dive into that in this conversation because there are certain. It’s an. This is a phenomenon that’s intrinsic to our human existence. And there are things that we can do to familiarize ourselves with death, to really abate it more and to become more comfortable with that reality.

Dani 05:19

I think what you’re talking about is actually not in contrast to what Keri’s saying. I think what you’re saying, what Keri is saying that is that if you’re human, you’re going to die and you’re aware of it. And that impact, what you’re saying is that that can manifest very differently. Maybe a Buddhist finds that to be the most enlightening and empowering thing on earth and maybe somebody else is completely crippled by that. So both, and you’re both right, it is universal. And.

Eric 05:50

Well, I guess the question is, yeah, that the definition. Is this just death awareness or death anx.

Dani 05:57

Yes. This is where we get tricky because the word anxiety in general is a tricky word because we. We have it living in the psychiatric constructs where the word anxiety is thought of as a pathological word. Word. And then we have these psychological psychotherapeutic constructs. And when we talk about something like death anxiety, that’s not pathological. Otherwise we’re saying that all of humanity is pathological, which would just not make sense. So I do think we need to.

Keri 06:27

Differentiate that and put this more in the bucket of the existential elements of just human experience.

Dani 06:34

But maybe it would help if I got concrete with examples as we define it. Okay, let me pause to give Kerry her credit, Keri. When I think about the giants that this conversation is on. You mentioned stands on. You mentioned Irvin yelling. But I would add Sigmund Freud and seldom Solomon and Ernest Becker. A lot of people to the list. I do think they’d very much agree with your definition. But to get super concrete, I was commuting to the city for a shift not long ago, and I saw a car accident in real time on the freeway. And I had this momentary uncomfortable fear. What if that had been me and my kids had never saw me again?

That’s a very obvious manifestation of death anxiety. But it can be so much more pervasive, insidious. Just today, today alone, and it’s only 11 in the morning, I put sunscreen all over my face when I woke up. I paid more to get organic produce at the grocery store. I came onto a podcast to have my voice recorded, my words recorded in perpetuity. All of those things could be influenced consciously or unconsciously by my underlying death anxiety. But nothing about that is pathological.

Keri 07:45

I just feel like I got this glimpse, Dani, into like your personal diary of Dani.

Dani 07:50

We’re gonna see what happens in the afternoon.

Alex 07:52

That coming on GeriPal is a mechanism for coping with our existential realization that we all will die. Dear listeners, listening to GeriPal is another way. And donating to GeriPal.

Keri 08:09

And we just learned that the license plate on Alex’s car is GeriPal itself. So a little self promotion there. And I think that these insights Dani’s bring up are spot on. It doesn’t solely happen when there’s a close call or panic and fear. There’s this wide continuum of death anxiety. It often can be inconspicuous or even camouflage. Think of it on a societal level. The way that ageism shows up in our culture, or ableism, our societal discomfort with aging and decline often stems from that concern about anxiety, about our mortality and that can get embedded into our daily habits and everyday choices. And it’s. It gets amplified in serious illness. That’s why it’s important for us to recognize when it comes to the foreground with our patients.

Eric 08:55

I am, I gotta say, I’m still a little bit confused because you keep on saying death anxiety, but part of it just feels like death awareness or like, you know, I’m gonna die. Maybe I cannot die as fast if I, like put on sunscreen and eat organic food or go on a walk or a hike. Because I do feel like the word anxiety has. I have tons of anxiety in my life over a lot of different things. Weirdly enough, I actually don’t like, the longer I do palliative care, I feel like the less anxiety I have over my own death. But maybe I’m using the word anxiety wrong. I am not fearful of it anymore like I used to be, like when I was a kid.

Keri 09:39

And I think that’s a shift in terms. I really appreciate that self awareness, Eric, because when we’re using this term death anxiety, it is in deference to the giants that we stand on. Folks like Irvin Yam, who’ve written about it in the existential space. And it’s not a pathology, it’s not something to be pathologized. I think what you’re describing is the sense of almost double awareness or a dual framework that’s also been written about in the literature where somehow we have, over time, as we develop a comfort with our mortality and awareness, there is a way that some greater human flourishing, it can inform our living and enrich our living. And that’s kind of akin to what Alex referenced earlier. Those Buddhist practices might get us there too.

Alex 10:28

Yeah. And I think it’s important for our listeners to understand we’re talking about the term here and we’re struggling about what term to use. And as Dani said before, we want to make sure we’re not pathologizing this and placing this within a psychiatrist only lens of using the term anxiety. And that awareness of our own mortality has prompted some of the greatest thinkers, works of literature and art in human history. And so we wouldn’t want to say that that’s a result of a human pathology. It’s a result of an awareness of our own mortality and our struggle to come to terms with that.

Dani 11:11

Yes. You won’t find this in the DSM. In the DSM. You won’t find it on the psychiatry boards. This came out of different pieces of Keri.

Eric 11:20

But then I’ll also say I have cared For a lot of people at the end of life. And like some people acknowledge their death and it’s not a big concern for, for them, it’s not something that they’re anxious about. But we also see people, some people are so very scared of the death, of what happened, that nothingness afterwards, or like what it means, that it’s just, it paralyzes them, family members. And it is, sometimes it does feel pathological.

Dani 11:52

Absolutely.

Keri 11:52

And I like that you’re highlighting and observing that spectrum of the human experience, Eric, because on one end of the spectrum we do see these patients where the death anxiety is immensely debilitating, or it might trigger a psychiatric comorbidity and need specialized psychiatric consultation or psychopharmacologic management. It can also sometimes be so exacerbated that it can lead to this almost sustained death panic or death terror. I had just a snapshot of this about a month ago. I was on an airplane flight and we hit tumultuous turbulence and I had just a moment of death terror.

And some of our patients live in that in perpetuity. But then on the other end of the spectrum, Eric, what you’re referencing is sometimes the awareness of death can actually be a catalyst for greater meaning, purpose, enlightenment towards one value. So we see that entire ecosystem in our work.

Eric 12:46

And what’s, what’s death terror? How would we define that? I mean, I think I could picture it.

Keri 12:55

Death terror is the phenomenon that, where the death anxiety ramps up to such a degree that it becomes paralyzing, where someone shackled in a way where it’s a panic. And that comes a lot from the tradition of Ernest Beckert, who’s written about terror management theory and that tradition. So what you’ve noticed clinically too, within certain patients, and I think that this is helpful, what you’re referencing in terms of the spectrum, for us to recognize that it’s a human phenomenon. It’s not always good or always bad, it just is.

And so for us to think about questions more akin to how is it showing up within this person at this particular moment in time? Is it actually helpful to the person or is it hindering them? And how is it showing up within us at this moment in time to be curious and non judgmental with those.

Dani 13:48

Inquiries, this is actually the paradox of death anxiety that we were talking about earlier. It’s both universal and incredibly personal and unique to the individual, like love or grief or many phenomena that we see that are part of the human experience but come out differently because of our inner landscapes. So every person by virtue of being a person is navigating this existential terrain, but there isn’t like one marked path through it. My compass may be leading me on a very different journey than yours. Mountain climbing. Mountain biker Alex over there is feeling this metaphor. I can see it. But just recognizing that paradox helps us renounce this idea that there’s a one size fits all component to death anxiety.

Eric 14:33

So given that, how should we be thinking about, like, we’re caring for our patients in front of us?

Alex 14:38

It’s.

Eric 14:39

It’s this thing I’m not going to use. Ubiquitous. Still haven’t convinced me on that. Just like love. Like there are some people that cannot feel love. So how should we be thinking about that with the patients that we care for since it’s. It’s ubiquitous, but everybody experiences it differently. Like, what are the things that we should be thinking about when we’re approaching patients in clinical settings? In a clinical setting, yeah.

Dani 15:02

This is a spot on question because it isn’t always obvious on the surface. Patients don’t walk into our room with a sign saying, death anxiety is driving me right now. But we’ve talked before on GeriPal about this idea of psychological formulations, of making a hypothesis about what’s psychologically behind the behaviors we’re seeing. So I would encourage us all to make more space in our clinical thinking for the psychological impact of life being finite, showing up in ways that might not be obvious. So maybe a hospitalized patient tells you, I have insomnia, doc, I need medication.

Well, maybe that’s because they’re in pain, and maybe that’s a medication side effect. But maybe it’s just that those dark hours of the night when there’s no input, no stimulation, no distractions to consume the mind, they create a void, they create an open mental space where these pushed away existential fears can suddenly have room to bubble up. So before reaching to the trazodone, we can ask things like, gosh, I wonder what it’s like for you in the quiet hours, or what’s on your mind when sleep won’t come.

Keri 16:10

And I’d like to double click on that, Dani, just to give everyone a potpourri of examples. Because sometimes death anxiety isn’t loud. Sometimes it’s just in the whispers of a symptom or a coping behavior. And our job is to tune in. You know, I see patients sometimes that have a sense of hyper control over a situation, wanting to micromanage every detail. And they might be trying to deflect from this existential angst or rigidity. To a care plan. I had a patient a couple months ago that every time it was discharged day from the hospital, another symptom emerged.

And what I discovered is that we thought going to rehab was this idyllic way of her to rebound her functional status. And she saw it as one step closer to her death. Avoidance of the medical system. Think of all the missed appointments that we see, or sometimes even when we see denial. It might not reflect a cognitive misunderstanding. Maybe it’s reaction of proximity to mortality that’s actually coming up.

Dani 17:06

All those patients who decline the palliative care consult because on some level, our presence symbolizes death.

Keri 17:15

Back to the reaper.

Dani 17:17

But if I were to flip the tables on you a little bit, Eric and Alex.

Alex 17:21

Uh oh, uh, oh.

Eric 17:23

This is, this is one of my…

Alex 17:25

Anxiety getting put down.

Eric 17:28

Shabbos anxiety.

Keri 17:31

Now that is ubiquitous.

Dani 17:34

No, I, you know, I think one of the things Keri and I are saying is that it isn’t good or bad. It’s not something to be fixed. Not that we could fix it or want to fix it or removed. It’s just something that we help people cope with. But in this vein of whether or not it’s good or bad, here’s my question for you. If death anxiety didn’t exist, would the field of hospice and palliative medicine exist?

Alex 18:00

Oh, that’s good.

Eric 18:03

So I would say that the number of palliative care providers would be significantly less. But I do think that the field would still exist because there’s more to it. Including advanced symptom management.

Alex 18:17

Yeah, yeah, that’s where I was going to go as well. And just as Eric said, you know, many of the reason that many of us go into this field is because we want to grapple with these existential questions, with these questions about mortality, what it means to be human and to be mortal, and we would lose that element. And you know, the hospice benefit, of course, is prognosis based, so that would be a problem. But if death anxiety didn’t exist, everything about humanity would be different. You know, if you were taking that ubiquitous view, you know, we wouldn’t have the major world religions, works of literature, art, music, poetry. What a thin existence. That would be very fair.

Dani 19:07

Way to go deep philosophical on us, Alex. And. But I would even push back a little bit on this idea of the advanced symptom management, because why did this field evolve initially to give advanced symptom management to people who were dying instead of initially evolving to give it to everybody? It was Naomi Sacks, phenomenal chaplain and human being here at UCSF You’ve had her on GeriPal. Keri and I had the honor of learning so much from her as an expert panelist on an HPM death anxiety workshop we hosted in 2024.

But Naomi opened my eyes to the fact that the efforts of palliative care are deeply energized by our individual and collective death anxiety. Without us all, whether consciously or unconsciously, having some level of death anxiety driving us, the need for thoughtful, compassionate care at the end of the life might not be so urgently recognized. And if we think back to when our field was born, there were these historical drives, shifts like the medicalization of death that were compounding our collective death anxiety by introducing cultural narratives of death as a failure instead of natural.

Keri 20:15

And we see that evidence in the literature that this over medicalization and these fragmented approaches to death can really exacerbate patients fears and distress. Like an overemphasis of extending life at all costs. It reinforces this cultural narrative within medicine of death as a failure or a lost battle rather than being a normative part of the human experience. Which pierces a lot to the heart of your question, Dani, and what we hope to name and verbalize in our field. Because we do inhabit this liminal space at the intersection of life and mortality and death, anxiety can be both a catalyst and also can be a barrier at the same time. It can cut both ways.

Eric 20:59

What’s the catalyst part? Like, how is this, I guess Alex was talking about that. It says it is a source for inspiration, for art, for religion, for a lot of different things. And an individual patient perspective. Somebody in our hospice unit. What’s the catalyst there?

Dani 21:17

Yeah, well, I mean, there’s the catalyst to the greater field that you’re talking about, Keri. But I think what you’re double clicking on, Eric, is this idea that it is tempting. It is tempting to just think about death anxiety as an obstacle or as a source of distress. When in actuality it can really be a catalyst for growth, for clarifying roles, there’s this. I have a favorite quote from Irvin Yellen’s book, Staring at the sun, which as an aside, staring at the sun. Most brilliant name for a book about death anxiety, right? Because like the sun, death is powerful. It’s ever present force. But it’s impossible to look at directly for too long. It will blind you if you try to. And yet we can’t ignore it either. It illuminates our lives.

So my inner nerd is revealing us. But his quote is, though the physicality of death destroys us, the idea of Death saves us. And we see this all the time with patients who reassess their values. Maybe they deepen connections with loved ones right before the end of life, or they have a renewed, renewed sense of creating meaningful legacy for clinicians. You know, engaging with our death anxiety, it not only helps deepen our capacity and our resilience, our appreciation of the work, but it can completely transform the ways we experience our own lives.

Keri 22:43

And that reminds me a lot, your question, Eric, of a powerful concept called post traumatic growth and adversarial growth, which has been described in the literature that many individuals report that from their experience of going through a major crucible event, they’ve had this psychological or existential transformation. And there’s data that supports this, that some cancer patients show that confronting their mortality really catalyzes deeper spirituality, deeper interpersonal relationships, greater personal attributes and strengths.

And I’ve witnessed this even in my own life where I’m just thinking about Paul Kalanithi. He was in medical school with me, a very dear friend, and he went on to become a neurosurgeon at Stanford and then tragically had lung cancer. And Paul’s book, When Breath Becomes Air is this profound illustration of the ways that he transfigured his suffering and finitude into this roadmap for deeper reflection and revelation. And we even have therapies that foster this within patients. I’m thinking about Harvey Chachenov’s diagnosis, dignity therapy or meaning centered psychotherapy that’s been pioneered by William Breitbart. Both are just evidence based ways to really approach deaf anxiety in a way to use it as a catalyst toward greater meaning and connection and purpose.

Eric 24:05

Okay, given that, I got another question. How much of it is for a lot of us in Pal of Care we go into this, like Alex said, we’re fascinated by the topic of death. We want to learn more about it. Like for me too, I was fascinated about it. Over time, I actually feel much less anxious about death. How much of this I’ve grown and I am much more attuned, which I don’t think is the case. I think I just became desensitized. It’s no longer seen so much death. It’s the one thing that we’re missing in as our society is nobody sees death anymore, but we see it all the time. So it’s just not that big of a deal.

Dani 24:51

I would actually, I’m going to use the phrase push back again. I would actually push back a little bit though, because this is where the power of narrative comes in. You’re framing it as I’ve stated it enough, so I’m desensitized. And I think actually the ability to walk through life in contact with the fact that there’s nothing special about you, that means that you’re not going to die today. Right. There’s nothing special about you that means that the patient should die, but you should stay alive. That is growth. People go into mindfulness practices for years, like silent retreats for months at a time to be able to be in contact with this deeply profound truth about humanity. So you say it, you say it as if it’s such a light thing, Eric, but it actually really isn’t. And I would say much of humanity, myself included, I see this every day and I still don’t want to die.

Keri 25:48

Yes. And Eric, just to unveil that curtain, even between Dani and me, we are close friends, colleagues, we even write on this topic together and our inner experience about death anxiety. We land in vastly different places in that ecosystem. We come to this work with different worldviews and ways of thinking about death or what comes in the afterlife. And that’s quite unique and distinct. Like for one of us there’s this deep sense of being grounded in a long held spiritual tradition and the truths of that tradition are believed. And for another one of us, there’s this presence with uncertainty which drives the search for meaning and finding meaning in the here and now. And so we even as providers, which I think is important how you highlighted this earlier, Alex. It’s almost a parallel process. We’re doing this for our patients while we’re also working on this within ourselves. And we might land in very different parts of that ecosystem.

Dani 26:45

There’s actually really cool data about religious beliefs and death anxiety. I don’t know where everybody on this call lands, but what they found in the literature which is so fascinating is that individuals with strong convictions, so either deeply religious or firmly atheist, tend to experience lower levels of death anxiety where those of us, whereas those of us in the middle people with moderate beliefs or uncertain beliefs tend to experience much higher levels of death anxiety. So interesting.

Keri 27:13

Yeah, there’s something about the congruence and this is shown in other parts of literature, congruence between expressed beliefs and behavioral lived realities of those beliefs.

Eric 27:23

It reminds me of some of the earlier studies around religiosity of end of life care. So they found that the more religious you were, the more aggressive end of life care that you used. But if there was positive religious coping versus negative religious coping, I know Dani’s going to say, you know, the good or bad coping is coping served you more versus less. That actually changes. It moderates that that aspect. And I got to say, in my own personal life, like, I’ve never seen an association between religiosity and fear or dread. Like, I would. I my. I was stunned by the earlier studies because I thought, oh, like if people believe that in an afterlife, they’d have less, you know, death anxiety or fear of death. But it never really seemed to play out in my clinical practice.

Dani 28:19

But it might be this degree of conviction piece that has only come out in the literature in the last couple years.

Eric 28:25

Yeah, differentiate even that, man. I think about the hardest cases where the, like the ones that people were most religiously convicted.

Keri 28:36

Yeah, but Eric, I’d love to circle back. You had reflected and disclosed something about your own life as an early career attending versus now. And I would love to even just share a part of my own journey with that because it made me it. It really compelled me to recollect a change within my own practice. A few years ago, this is on a very personal note. I encountered some health issues that introduced this constellation of symptoms, many of which will likely accompany me for the long haul. And that’s given me just a minor snapshot, just a morsel into what our patients endure.

And at first, those relentless, persistent symptoms tempted me a lot toward despair. Despair. But somehow, over time, I began to wonder, what if these unceasing symptoms served as an unceasing reminder of my transience, of my mortality? And rather than those symptoms being something to be feared, could I see it as something that really sharpened my attention on how to use my time, my limited time, and how to utilize my focus? And that shift has come completely reshaped my clinical work. It’s been a paradigm shift where when I first started in the field about 10 years ago, I leaned on these mantras that really helped me stay anchored so I wouldn’t get swallowed up in the death anxiety around me.

And now the ten years later, as I’ve gone through this sort of crucible element within my own life, my inner voice is really different. I often, before going into a room, will say to myself, before seeing a patient, I’m just a few steps behind you on this journey through life, whether it’s 30 days or 30 years, just a few steps behind on the same finite road, just a few steps behind. And that sort of unceasing awareness of my mortality has really helped me accompany patients with greater humanity and connected attunement. And I share this story because I know it’s not unique. I know within the field, we all have these hidden hardships or losses or griefs, and they make us more raw, more vulnerable and more available potentially, if we’re able to work through them constructively. And Dani, I’m thinking about within your own life that when you had one of your daughters in the NICU for 95 days and how that reshaped your relationship to uncertainty.

Dani 31:07

Keri, I love this story. And I think what you’re talking about. We talked so much earlier about the differences between people. Everybody’s different. But you’re hitting on the. The variation within people. Alex and Eric, I imagine, due to a lot of life circumstances. And Eric, you’ve already kind of said this about yourself today. The struggles and strengths you grappled with when you were trainees were different than when you were new attendings, which in turn are different than this phase of your career and will undoubtedly be different in 10 to 20 years from now. Assuming, of course, that we haven’t all died before then, which I’d rather avoid thinking about.

Dani 31:44

Yeah, yeah.

Alex 31:46

I love what you said, Keri, about the thoughts that you sort of recite to yourself before you go into a patient’s room. And I love. Thank you for sharing the story of your personal journey in making meaning out of this illness experience. And it seems to me that at the beginning you talked about the sort of four. I forget. What were they? Precepts or something? What were they?

Dani 32:10

Four concerns.

Alex 32:11

Four concerns. And that death is at sort of central. The central concern that leads to all the others that might lead to you to create, you know, to focus on making meaning out of the now, to extending your social relationships with others. And I guess I would also say I worry a little bit about my GeriPal, co-host, because there are two sides to this becoming used to death. Right. And that maybe there was a healthier aspect to the beginner’s mind approach that you had earlier in your training about death. And that there is kind of a potential dark side about desensitization, depersonalization, just sort of disconnecting from this in a way of protecting yourself from it so that you become inured to it. And I worry about that with some people in palliative care. I’m not saying it’s you.

Keri 33:05

Absolutely.

Eric 33:06

And Alex, is this an intervention? Alex.

Keri 33:10

Alex, I really have the psychiatrist.

Dani 33:12

Wait, no, because Alex is suggesting, and I love this hypothesis. Alex is suggesting that Eric’s laissez faire. I don’t care about it. Stance to death may actually in itself be a manifestation of defense from underlying death anxiety, a way for him to not have to be in contact.

Keri 33:31

Well, and we witness this continuum in medicine all the time that you’re highlighting, Alex. On one end of the spectrum, there’s the vulnerability to depersonalize, to depersonalize our care with the patients, to distance ourselves from the patients, to dehumanize them. On the other end of the spectrum is an over investment, an overcompensation, an over identification where this patient’s suffering somehow becomes our own. And I tell my trainees all the time, don’t give in to the temptation of the messianic complex that sometimes exists within our field.

This belief that somehow we’ll be the salvific savior if we can over identify or do the three hour family meeting to make it a quote, good death. And what you’re calling for and really calling us toward, Alex, is this sort of healthy integration of this is all a part of the human experience. I’m going to accompany you with therapeutic presence. Not over investing where it becomes my own, but also not detaching so much where it distances.

Eric 34:36

Yeah, and I guess that, you know, Alex’s question kind of leads me to think about. So I think that I still struggle with this because I think I am acutely aware I have death awareness. Like I am, I’m aware of my mortality. I think I do things because of that awareness. I just don’t feel that sense of dread or fear that I used to feel around this. I remember as a kid, like lying in bed and like, what does this all matter if we’re all gonna die? Like, what’s the point? Like, I got like maybe 80 years left, like, and then nothingness, blackness, like that scared the bejesus out of me and I don’t have that anymore.

Keri 35:16

Yes, I feel like that nihilistic black hole has disappeared again.

Eric 35:21

Maybe it’s. But I also think about in some ways, like nowadays, in my mind, I’ve cared for a lot of patients who’ve taught me also, like, so what? So you’re dead. It’s no longer a source of anxiety. If anything, it’s a relief. Death is the relief from all of your other anxieties, all of these other symptoms. And Keri, you bring up like these symptoms for some of our patients, they’re not anxious about death. They’re aware that they’re dying. If anything, it’s the ultimate relief of what they’re going through right now.

Keri 35:52

What you’re double clicking on right now, Eric is also reminding me about our own countertransference in this Experience too, because sometimes we experience that relief when a patient dies. And I first time I felt that as an early attending and I felt so guilty about feeling relieved that that patient was now off of my list because they had died. And I think that you’re really highlighting the critical nature of even the way that our own relationship with mortality, death and reactions is highly informative in terms of data points for how we can do this work in a sustainable way.

Eric 36:34

That is a great point.

Dani 36:35

Eric is pointing out an alternate formulation for his own psychology, which is that he. That you have grown. You have shifted death anxiety from a scary thing to a catalyst, a thing that makes you more grateful for the present, more in the present, more able to let go of other worries because death’s coming anyways.

Keri 36:57

And that’s been written about in, you know, Gary Roden and Juliet Jacobson. I wrote a paper with her about this principle of double awareness or the dual framework. It’s this holding a dialectic where the awareness of our finitude and transience actually eventually starts to inform and enrich our living.

Eric 37:17

So I gotta ask then, so as we. As we care for patients in front of us, because I’m also hearing this death anxiety is both conscious and unconscious. I get if it’s conscious, I can talk to people about it. What the heck do I do? If it’s uncle. Maybe I am just not recognizing it because it’s so deeply unconscious that. And I’m not the smartest person that is just not like, what do you do about unconscious death anxiety?

Keri 37:45

So what can this comes from? Freud. What we can’t say saying within ourselves or verbalize often comes out in action, sometimes aberrant actions or behaviors. So if we can’t at least verbalize it within ourselves or with a colleague, or sometimes if it’s therapeutic to the patient, it might come out in over treatment, overreacting, recommending full code or the next chemotherapy when we know that would be to no avail.

And so one part of the work is that inner work of bringing things that might be more subtle and camouflage or concealed a bit more to our awareness. And I also don’t want us to get too meta about it or too overly scrupulous because the. The freeing, liberating thing here is that because it’s such a ubiquitous part of the human experience that we can actually be okay with it all being around and we don’t have to be overly, always overly scrupulous towards it.

Dani 38:45

But this literally just came up for me in clinic because, Keri, I think part of what you’re saying is there are a ton, a ton of clinical tools we can reach to, but a willingness to really look within and confront and hold and get to know our own existential baggage is the best thing we could do for patients. But this came up for me in clinic, despite all the work I’ve done to grow in this space. I opened the chart of a new patient earlier this month and I immediately saw that she was my age. And my heart sank a little bit. And I met her and very quickly learned in the interview that she has three kids just like I do.

And there was a part of me that was very much with her in a compassionate way. I’m a kind person, but there was another part of me that was secretly looking for pieces of her story that made her different than me, that made her other right. On some level, I didn’t want to be in contact with a world where 41 year olds with three young kids die. And I even found myself colluding with this patient’s wildly overly optimistic comments despite an incredibly dire prognosis, more than I usually would with patients. And I remember that moments after I ended the visit and I called my trusted outpatient social worker and I said to him, I said, I need your help accepting in my heart, not my head, my head gets it, but in my heart that I may die way before I want to, because otherwise it’s going to be really hard for me to accompany this young mother of three in the way that I want to accompany her.

Our ability to accompany patients in their existential struggles is deeply tied to our willingness to confront and hold our own mortality. And not all of us are are as experienced as you in this, Eric. Because I will tell you, I haven’t succeeded at this task. It’s not checked off my list. I am a work in progress in every sense of the phrase. And right when I think I’ve gotten it figured out over here, it just pops up somewhere else. But I am committed to being engaged with the inner work, which can be accessed in so many ways. Like for me personally, sometimes I write, sometimes it’s mindfulness, sometimes it’s therapy. Sometimes I drive to the ocean because I know that I need to stand in front of its vastness and just take in what a grain of sand I am.

Keri 40:53

Dani, that account that you just gave is a powerful reminder of the vitality of our interprofessional teams and the transdisciplinary work that we do in our field. And it’s reminding me of this practice that we have on The Stanford inpatient team, where every Friday for 30 minutes, we have this routine practice where we all pause, we put our patient lists and phones aside. One of our chaplains or social workers leads us in a process rounds that is not about our clinical work, but more about some of the themes that have come up within our own selves during this week.

It’s sort of a collective self awareness of what’s happening within us and how it’s influencing how we’re showing up. And it’s really deepened our ability to show up more authentically, first with ourselves, with one another on our inpatient team, and then with those consulting teams, and hopefully ultimately some ripple effects of how we’re showing up for our patients and families. And I’ve really treasured that practice.

Alex 41:56

And I love. I love these stories, these examples, these processes, these ways of coping, these practices. And I’m sure our listeners will love these too. And also the beautiful language with which you use to bring this home clearly to our listeners. And I would posit that for many of us, this journey is a struggle and that both elements may be true at the same time. That there may be ways in which we are moving, moving more deeply in our engagement with our own mortality and that helps us care for our patients in a deeper sense.

And there may be ways in which we are becoming more used to death because we are surrounded by it at the same time. And that for those reasons, we have to continually have some sort of practice reminder, something, some sort of engagement that brings us back to. I don’t know what the right term is, but the central purpose that brought us to palliative care in the first place.

Keri 43:00

And Alex, I think that’s also a reminder to me that it’s not about perfection, it’s about connection.

Dani 43:06

Yeah, the genuine Perry preterism.

Keri 43:09

I know I’m like a broken record, always saying this to our trainees. It’s not about perfection, it’s about connection. Ultimately, at the core of death anxiety is this core profound longing that people, patients, and we ourselves have for human connection to not be isolated because we all ultimately die alone. That’s like an existential phenomenon. And so the more we can authentically attune ourselves and accompany our patients toward that connection, rather than the striving for perfection, is really an intrinsically powerful aspect to what we can offer.

Eric 43:43

Yeah.

Dani 43:43

And Alex, when I’m with patients, I will often, like, visualize the size of my pores as this thing that I can flex. I can let more in or I can let less in. And there’s room to switch it just based on what we can handle in the moment. We can open them more or open them less, but we never want them so open that we just get engulfed by the patient’s experience and we’re living in some kind of place of distress. But what you’re also talking to is we never want them so closed that we’re not able to connect to them on the deeper level that we’d want to, if that’s protective for us to have them super closed. But it doesn’t allow the level of depth and accompaniment that we are striving for. So being able to have our pores somewhere in that middle ground where we’re taking in enough, we’re still in contact with humanity enough that we can accompany without going too far to one extreme.

Alex 44:39

This is great and this is deep and Eric has a question. But I want to ask what our listeners may be wondering, which is what is the appropriate dose of benzodiazepine for our patients experiencing?

Dani 44:52

Depends on the formulation.

Eric 44:55

Oh, I forgot to mention that’s my trick for getting rid of death anxiety is I’m taking high doses of benzodiazepines.

Dani 45:03

But there are some patients we have, there are some patients who, when they’re going to go into that scanner, the thought that the results are going to come back and show something is just for those few days before getting in the scanner, it ruins their world. They’re envisioning the finding on the results. There are death anxiety is off the charts. And you know what I do? I give them a benzo. I give them a benzo for those days, which gets us this. I think, like, if there was one thing I really want everyone to take in, there isn’t a desired outcome here.

Eric 45:38

Yeah.

Dani 45:38

One patient with death anxiety that’s so debilitating may need psychotherapy or mental health support. But another one with more moderate death anxiety might just need us to accompany them, to be willing to go there, to hold space, journey it. Another might need a little more handholding. Maybe they need us to help scaffold a gradual exposure to fears. We start with words like uncertainty and worry and we build up slowly to death, helping the intolerable become tolerable. And then there are patients, maybe this will be you, Eric, at the end of life. But who benefit most from us simply just celebrating the stories of legacy and meaning that ground them. It’s process over.

Eric 46:18

Yeah. Or like maybe, like Alex is saying, maybe increasing my intolerability of it. Like actually, like thinking about, like what, what does it Mean to grow. And is it. Is that also. You know, I’m trying to get to like, what Alex was saying. It’s like this idea that death anxiety is not something that you just want to get rid of. And that’s what I’m hearing. Everybody is saying it’s this human experience and it’s this balance. I’m hearing from Dani, it’s neither good nor bad. That means how we approach it and how we care for our patients, how we care for ourselves is it kind of depends.

Keri 47:01

And I like the types of questions that you’re asking are about holding that dialectic and recognizing that also that every strength has its shadow. So the strength, this attribute and asset that I see within you, Eric, of your comfort, your comfort with death, it could have a shadow there too. And so it can be a both and. And not the either or.

Eric 47:22

Yeah. And it kind of goes to like, if we’re not going to put a judgment, good or bad, strength is probably not the right because I don’t see it as a strength. But honestly, I feel like it’s a desensitization. I’m not sure that’s like a strength, but it’s this thing.

Dani 47:36

Well, not to bring us back to our coping lecture, but what you’re saying is that in some ways it serves me right. I’m not crippled with fear the way I may have been earlier. And in some ways I see you questioning right now. Maybe there are ways. It doesn’t serve me.

Eric 47:51

Is there a downside to it, depth.

Dani 47:54

Or a certain contact with something that’s fundamentally human? It’s a great question for us all to be. This is actually the exact inner work that Keri and I are saying we all need to be willing to do if we want to deepen our capacity to authentically attune to people.

Eric 48:09

Okay, I’m going to go back to Alex’s question, though. We’re not going to be talking about benzo, but when we’re like. And I loved hearing, like, how do we pick up the. That this is. People are being affected by death anxiety. Sometimes it’s like the symptom, you know, the dyspnea. Like, it’s not just dyspnea. It could be that that dyspnea represents for them their mortality or, you know, the worsening pain may be a representation. Oh, fudge. I am dying. Like, what do you do about. Like, how. What’s that next step? Like, what should. So we’re diving into. Tell me more.

Dani 48:47

Yes.

Eric 48:49

You get a sense that there’s component of Death anxiety.

Keri 48:53

There are aspects of patients that definitely make them more prone and vulnerable to death anxiety, systemic oppression, trauma, certain cultural narratives, unresolved personal conflicts, unfinished business, insecure attachment styles. Those are all things that can really exacerbate death anxiety. And there’s literature that shows that on the flip side of that are the resilience factors, where the evidence shows that if we can mobilize those elements of a patient’s experience, it can really be a buffer from that death anxiety or death terror, death panic.

How can we enhance patients secure attachments in our own clinic visits? By showing up in ways that are consistent in attune, where they feel accompanied and seen. How do we give patients a life narrative that feels cohesive, where they can name parts of their life where they’re proud of things, and it softens that death blow and death anxiety. How can we give them a sense of life completion where unfinished business gets undressed, or they’re emboldened to reconcile relationships? You know, our field is so good about things like legacy projects and fostering generativity, asking about that family photo at the bedside side, and really bearing witness to generativity. So all of these little techniques are ways that I feel our field is already endowed with in terms of really bolstering the natural assets that patients come with to mitigate a heightened sense of death panic or death terror.

Dani 50:28

And, Eric, though, I do ask you, like, asking concretely, like, what do I do with it? Right? They have this pain. What do I say? And we’re wiggling around this one because it’s just so not one size fits all. I had a patient, actually. She’s in remission in my outpatient palliative care clinic, and she came to me complaining about pain. She complained about pain. I was writing all the info down, and then finally I was like, how high is this on a 10 scale? And she was like, about a 1.5. For a moment, I was like, why the heck have I just spent an how we’re talking to you about this. And what I came to learn was that what was distressing for her is that anytime she felt it, it came with this thought. What if my cancer’s back? What if my cancer’s back? And that’s why she cared so for her.

I named that, and I named it. Sounds like, you know, the discomfort isn’t actually the physical discomfort. It’s like the. The way that it makes you feel so much more in contact with your vulnerability than you want to be. And she was relieved, and she could talk about it. But it’s not that I would name it with everybody. It sort of depends on the person. And so our job is to. To even just have our antenna up. Maybe this is what’s going on here. And then to think, well, how. How might I be able to serve? Because sometimes what’s more important than what we say to our patients is the way we’re able to be with our patients, to show that we can really.

Keri 51:55

Be present to it and stay intact and to not disintegrate ourselves, to lean in rather than avoid or try to abolish it. Like that being is the therapeutic modality.

Eric 52:08

Even just talking about death and dying, I think is something that people don’t have.

Keri 52:12

It’s an exposure therapy in and of itself.

Eric 52:15

And I guess that’s the other question. Sometimes, like, when I talk to people, one of my favorite questions is, like, when I ask people, like, do you worry about your own death or dying? And if somebody says no, well, why not? Like, just because it’s kind of weird not to. It’s not the norm. And I’d love to know. Maybe that’s my own fascination with death and dying. Like, why? Like what? What doesn’t scare you about it? And I love the answers that I get. Is. Is that a stupid question? Do you think that that’s reasonable to ask?

Keri 52:50

I think it is, in as much as it’s not our own emotional voyeurism.

Eric 52:55

Yeah.

Keri 52:56

It’s not us trying to somehow work out our own garbage within ourselves.

Eric 53:02

But going to Alex’s point, isn’t palliative care, all our emotional voyeurism, the reason why we went into this field?

Keri 53:09

But I always take a little pause some when I’m asking a question that’s outside of my normative sense scope and out of curiosity of am I doing. What’s my motive here? And there’s always a mixed motive. And is my primary motive really to be an instrument of therapeutic healing and ideally flourishing for this patient? Because these are. These are the most sacred illuminative moments of the human experience, and we get a backstage pass into those with the work that we do in our field. And so to be attentive to.

Eric 53:42

To.

Keri 53:44

The aspect of how sacred it can be and how illuminative it can be is helpful.

Alex 53:50

And I’ll say that in my clinical work, which is Eric and I both practice clinically doing inpatient palliative care consults, so much of the anxiety we see around death is not from the patients who often have dementia or critically ill in the icu. It’s from the caregivers, the family, the loved ones who are both afraid, terrified even of losing their loved one. And a piece of that is a reflection about their own mortality.

Eric 54:21

Great point.

Alex 54:22

And this is why, you know, in our fields, in geriatrics, palliative care, so often the unit of care is not just the patient. It’s the patient, their family, their inner circle, their loved ones, those who care about them the most. And that our responsibility is not just to the patients, it’s to the relationships and the coping mechanisms that the family members are employing and how adaptive and maladaptive they are as they make decisions for their loved ones.

Dani 54:47

And to riff off of that, you know, we are obviously grappling with this, but what is our role in supporting our colleagues? Like, how many times have we asked ourselves, why is this consulting physician unable to just share the prognosis? And we say it with frustration, but can a part of us think about what might be underneath it for that consulting physician? What would it mean for them to share the prognosis? Because there’s a lot in our humanity under the surface for all of us. We’re all out here with pretty good intention.

Keri 55:17

Yeah, but however, are we enacting denial or are we enacting that sense of death avoidance?

Eric 55:25

Okay, my last question is, we’ve talked about a lot of different things here, but if, like, there’s one key thing that you want people, like, if you had a magic wand, you can get providers who are listening to this podcast to do one thing, what would it be?

Dani 55:44

So much. I probably would land. I said it before, but I’ll say it again because I think it’s important enough. I would probably land on this idea that our potential as clinicians really lies inside of the process over the outcome, the process of self reflecting, of deepening our capacity to authentically attune to patients, existential distress, however it comes up, and there is a risk to that process. Like, I know when I recommend people do this, it comes with a risk. There’s a vulnerability to it. It’s really nice for us to be the providers, the clinicians, and for them to be the patients, the people who are subject to how fragile the human condition is. When we do this work, we greatly deepen our capacity, but we also sort of put us all on one playing field, this one human playing field. And that can be scary to do. It’s a lot easier said than done. And like Harry attested to earlier, a lot of beauty can come out the other side of it, too.

Keri 56:50

So this conversation is also reminding me of Freud. And in his writing he said the unconscious did not, does not believe in its own death. The unconscious believes it’s immortal. So there’s this taken for grantedness that we all have within the continuity of life, that it’s not pathologic like you said before, it’s quite normal. And it allows us to show up, to see our patients, to love, to make plans. And yet in our field and in our work, we have to hold both of these truths at once. Where allowing us to behold our own mortality and limitations in finitude can be a source of informing and enriching our day to day lives. To make it more of a life of thriving and flourishing and to therefore also be more open as an instrument to be that for our patients too. To really accompany patients being a light with their darkness when they’re having to traverse those spaces.

Eric 57:49

Wonderful. And that kind of goes into maybe not fearing the reaper so much.

Dani 57:56

The reaper taught us a lot today [laughter]

Alex 58:07

(singing)

Eric 58:46

Dani, Keri, it’s always great to have you on this podcast.

Keri 58:49

Thank you so much. We appreciate your engagement.

Eric 58:52

I love having you on. Looking forward to maybe what our next episode with both of you will be, but we’ll keep that a secret from everybody. It’s kind of a secret for me too, because I don’t know yet [laughter].

Dani 59:03

We might be dead before then. [laughter]

Eric 59:05

And you never know the way things are turning out nowadays. Yeah. And with that, I want to thank all of our listeners for your continued support.

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