All beings in this world, all bodies must break up: Even the Teacher, peerless in the human world. The mighty Lord and perfect Buddha has passed away. — The joy of renunciation in The Radical Buddhist.

 Of all the wonders that I yet have heard, It seems to me most strange that men should fear, Seeing that death, a necessary end, Will come when it will come.— Julius Caesar, Act 2, Scene 2. William Shakespeare

With the sudden appearance of COVID-19 that has been killing the elderly at an alarming rate, doctors may be forced to make life and death decisions based on age, underlying medical condition and the need for respirators, something unthinkable in the near past. Emergency Medical Service (EMS) teams who cannot find or restart a pulse while administering CPR on adult cardiac arrest patients have been instructed not to bring those patients to hospitals. How the COVID-19 epidemic will change our approach to death remains unclear as of this writing. In this regard it is noteworthy remembering what the Roman Seneca commented some 2000 years ago: death is sometimes a punishment, often a gift, and for many a favor.

Death is a dreaded word no living human being wants to hear. But ultimately, all of us have to face our own death or that of our loved ones. For only one thing is certain in our lives: the fact that one day we will die.

Medically, death is declared when an individual sustains either an irreversible cessation of circulatory and respiratory functions or an irreversible cessation of all functions of the entire brain, including the brain stem. On the other hand, if a person experiences the “irreversible cessation of all functions of the brain,” he or she is considered legally dead. With the availability of life-support measures, a legally brain dead subject with a beating heart may be kept “going” until the decision is made to remove all life-support measures.

The process of dying, of how, when, and where, has changed over the last century. In the US, nearly two-thirds of deaths occur in a hospital environment, in the intensive care-units where patients often undergo all sorts of complex procedures, including surgery and other life-extension measures. Some of these patients are transfers or admits from nursing homes, and many are oblivious of their life-expectancy. Their relatives not uncommonly plead with the doctor: “Please doc, do all you can,” and often the doctor obliges seeking consultations for each failing organ from a host of specialists: cardiologists, pulmonologists, gastroenterologists, kidney specialists and surgeons, all doing their thing, as if to maintain each “organ” disregarding that they are human beings, whole entities rather than parts of an unraveling body. Yes indeed, modern medicine can prolong life, but ultimately cannot avoid death. These so called “medicalized deaths” are not exactly what people desire. Polls conducted by the Kaiser Family Foundation and The Economist report that most healthy people hope that they will die at home peacefully, free from pain and surrounded by loved ones. However, that doesn’t mean that their wishes will hold when they are faced with a catastrophic illness such as COVID-19. In the past, I have encountered patients and their relatives rescind DNR (do not resuscitate) instructions to insert a pacemaker in a terminal patient.

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The insecurities associated with death, and the much argued presence or absence of an afterlife compound our anxieties and add to the fear of dying. One can argue that death is preferred to severe disability or suffering with its devastating effect on quality of life. However, some would strongly hold a counter position that life is sacred, ordained by God, and, nobody has the right, the subject or his doctor to end life prematurely, no matter how miserable the existence. Indeed, few people if any will celebrate death with champagne as Anton Chekhov did. Chekhov’s wife, Olga was with him when he passed away. She writes that they had ordered champagne; he took a glass, and turning his face towards her, he smiled at her and said: “It’s a long time since I drank champagne.” He calmly drained his glass, lay down quietly on his left side, and shortly afterward, fell silent forever.

In the US, in contrast to some European and Canadian cultures, we prefer to let life ebb away and ultimately extinguish itself. I have been following a patient for several years on whom, years ago, I had performed a successful ablation of a rapid heart-beat. Recently however, she was going downhill with severe limitation due to a lung condition, weight loss, and a previous cancer that left her with a single lung, now diseased as well. She was in a nursing home barely able to breathe. She said to me: “I am waiting to die a miserable death…I wish I would go quickly.” Her feelings are entirely honest. If ethicists and psychologists confirm those wishes are genuine, then one might ask whether society, cultural norms or “religious righteousness” can or should deny them. With the sudden appearance of COVID-19 doctors may be forced to make life and death decisions without the input of the patient or his/her spouse or relative.

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As much as death is abhorred in our society, even in the setting of terminal cancer, heart failure, and old age, the recognition and understanding of the importance of quality of life and of death itself, a subject little talked about, let alone discussed, assumes considerable import. Unlike Asian societies, Western culture, more so the American, hold in disfavor old age and death. In other societies, particularly in the Eastern, old age is revered, and in some, death has no absolute finality.

One might argue that in affluent western societies there is much to live for. And so, nobody in his/her sound mind wants to die even if the ravages of age or illness are evident. Undoubtedly, a healthy mind irrespective of age and disability can amply enjoy the fruits of living, particularly if one has a caring, loving family or one has “purpose” to keep on living. It is pleasurable for an older person, a matriarch or patriarch of the family, even if disabled by disease, to be surrounded by children and grandchildren and great-grandchildren for some or all festive occasions. Furthermore, not uncommonly, in terminal medical conditions, the will to live or the “will to die” is highly personal. Even in the most desperate of situations, death may not be a welcome alternative. A patient of mine who survived the holocaust and is now over 90 years of age and disabled, but with decent mental faculties, told me that in the Nazi concentration camp she had the option to get electrocuted on the fence while trying to escape, and some did just that. She was afraid of death and rather preferred to live a tortured existence. She survived, came to America, and raised a family. Even now, this courageous woman desperately wants to go on living, and even today, having witnessed the ravages of history, and having made a life for herself and her family, she still fears death.

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OUT-OF- BODY EXPERIENCES

Some of my patients who survived an episode of sudden cardiac death, and lived to recount the experience, describe seeing their long-gone ancestors around them, perceiving detachment from their own almost lifeless bodies, and looking down at them. Immediately, thereafter, they passed through tunnels into another universe of scintillating lights, and subsequently were pulled back into their bodies at the very time of successful resuscitation. Obviously, we do not have clear scientific explanations for these perceptions. But I do believe, after questioning my patients at some length that these are true and rather repetitive perceptions in people who survived an episode of sudden cardiac death, and not a fancy of their imaginations, nor perhaps dream-like states. Quite astounding is the fact that these experiences have, most of the time, been positive and not frightening. Whether they occur during activity at some cortical level due to an alteration of neurotransmitters as a result of the cessation of blood supply to the brain, or they reflect the detachment of the living energy from the body, perhaps can only be determined by scientific experiments such a functional-Magnetic Resonance Imaging (fMRI) or Positron Emission Tomography (PET) scanning during a cardiac arrest, something that is practically impossible to accomplish in the setting of a non-beating heart and no blood circulation.

On the other hand, electroencephalographic (EEG) studies that determine brain activity have been recorded during blackout spells (in the condition known as vasovagal syncope) induced by head-up Tilt Testing, where the bed is tilted to a 70, or 80-degree angle, for a period of 20 to 30 minutes. These studies reported by Ammirati F and coworkers [1] showed that in patients who blacked out because of temporary cessation of heart rhythm, there was a sudden reduction and disappearance of brain wave activity (i.e. a flat EEG) seen at the onset of blackout spells. The EEG normalized immediately after recovery. This study obviously proves that loss of consciousness even over a short time span is accompanied by loss of brain activity. Moss and Rockoff [2] reported on a 62-year-old woman who had simultaneous EEG and ECG during emergent carotid artery surgery. While the surgeon was closing the incision, the patient developed cardiac arrest. There was loss of EEG activity within 15 seconds of heart stoppage and activity returned almost instantly after resuscitation. In animal models of cardiac arrest produced by rapid injection of potassium chloride, a flat EEG occurred within 25 seconds of cardiac standstill. These studies do show that the occurrence of cardiac arrest with resultant loss of blood flow to the brain is associated with a loss of brain electrical activity. Does this then imply that extrasensory perceptions during cardiac arrest are not related to brain activity, but rather to the release of another form of energy from the body?  

THE CONCEPT OF AFTERLIFE

Not uncommonly, fear of death, or lack thereof, and the idea of an afterlife are strongly rooted in religious beliefs. The teachings of world religions: Christianity, Islam, Hinduism, Buddhism, and Judaism have different philosophical viewpoints on these matters. In Judaism, the Torah is silent on the presence of an afterlife. Instead, it entirely focuses on Olam Ha Ze, meaning this world. This view is contrary to that held in the Christian and Muslim faiths, where Heaven is the eternal realm for chaste people, and damnation into Hell for evil ones. I have met dying people of the Christian faith who expressed certain contentment that soon they would attain the Kingdom of Heaven and perpetual life in the presence of Christ. Yet, despite their belief in a better eternal kingdom ahead, these believers were eager to delay dying. In the far eastern religions of Hinduism, Buddhism, Jainism and Sikhism, and even in Kabbalistic Judaism, an afterlife is grounded in the theology of reincarnation, in which life is reordered after death as another earthly life in the physical world. The transmigration of souls, or samsara, results in the passage of a soul from body to body as determined by the force of one’s actions, or Karma, in the recent past. Successive reincarnations attempt to achieve a superior grade of consciousness, which ultimately leads to liberation from the cycle or rebirth, and the attainment of Moksha. In Tibetan Buddhism, Bodhisattvas are not reborn through the force of karma and destructive emotions, but rather due to the power of their compassion. Thus, the Hindu and Buddhist do not view death as an end in and of itself.

Death, on the other hand might be more difficult to accept for a Jew, in contrast to a Christian or Muslim, who has the promise of Heaven. I have witnessed prolonged and futile resuscitative codes on Rabbis sometimes for over an hour, when the doctors in attendance well knew that the effort was useless.

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Reconnecting in the After-Life

A single person is missing for you, and the whole world is empty.― Joan Didion, The Year of Magical Thinking.

There is a strong desire for a loved one, particularly for a spouse or a parent to communicate with the dead person, and this is often achieved through mediums.  One of my patients, whom I shall call Mary, related her story in search of her dead child, whom I shall call Mallory. Mary together with her husband and her teenage son had a meeting with a psychic. She said to me: “Immediately the psychic said there was a little girl present and she would not stop talking. The psychic’s voice changed to that of a little girl, and, looking directly at me, said, ‘“Mommy, you are crying too much. Please stop. I don’t throw up anymore and I can run and dance. I am so happy here. Those doctors can’t hurt me or call me names anymore. Please stop crying. I am okay.”’ To her father, she asked that he should not be so sad. To her brother, she said she loved him and made reference to a tattoo he talked about. She also said that what happened to her was supposed to happen, and none of them could have changed it.

“The tears were flowing heavily,” said Mary. “We heard a lot from Mallory that day. We all left there with a new peace in our hearts, and I felt a huge weight had been lifted off my shoulders. I often think back to that reading and how it played a major role in my being able to move on.”

After my wife died of cancer at a young age of 40, I searched for her wherever I went, in whatever I saw. I expressed these feelings in a poem I wrote:

“Amid flowers: I searched her face;

in the ocean wind: I heard her cry;

in the falling star: I saw her leap;

in the snowflakes: I felt her breath.”

Recently, a friend of mine whose wife died of cancer claimed that he felt her presence at home in the form of shifting light. Undoubtedly each encounter, whether real or a figment of one’s imagination, provides relief and closure to overwhelming grief. Needless to say, it’s not the objective of this essay to refute or confirm these extra-sensory perceptions; after all, the existence of anything only occurs when we perceive it, and so if one perceives and believes that the person felt the presence of the dead person in a parallel universe, so be it. Something that we do not perceive for all practical purposes does not exist for us, but might exist for others. Undoubtedly, the lonely deaths due to COVID-19 without the presence of loved ones will leave families grieving and empty for a long time with a strong desire to connect in the afterlife.

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The Concept of Mass/Energy Applied to the Afterlife

The much acclaimed, Portuguese poet Fernando Pessoa, though his heteronym, Bernardo Soares, said of death: When I see a dead body, death seems to me a departure. The corpse looks to me like a suit that was left behind…

In death, all the physical, biochemical, and mental energy within us, the very idea in our brains of who we are and what we are, is energy that dissipates slowly as the body cools down. The French philosopher Rene Descartes said: “I think, therefore I am.” One can therefore pose the questions: Where does the energy spent on thinking of who we are, and other mental functions disappear? One of the fundamentals of physics is that energy does not die, that it cannot be created nor destroyed—it simply gets converted into other forms of energy. And so, the body ultimately reverts to dust, intermingling with the soil of the earth, passing on its mass/energy, or rather converting into other forms of energy, such as biochemical energy into plants and all living beings—providing nourishment to mother earth, the continuum cycle of death and rebirth. An important common belief in native American culture is profound respect for Mother Nature—the earth, the sky, the trees and the animals, and that we humans are a part of nature. Our suffering, our illnesses are not different from those of the animals around us, and when we die we become part of that from which we came: from dust to dust. Our biological material is recycled and re-distributed; and even if we do not believe in an afterlife we live on as biological matter in mother earth in the cycle of life and rebirth.

But of the soul or the spirit of man—where does that energy go?

I am incapable of conceiving infinity, and yet I do not accept finity. I want this adventure that is the context of my life to go on without end. — Simone de Beauvoir.

I depart as air—I shake my white locks at the runaway sun, I effuse my flesh in eddies, and drift it in lacy jags. I bequeath myself to the dirt to grow from the grass I love…Walt Whitman

In E = mc² Einstein reached the conclusion that mass and kinetic energy are equivalent, and can be converted into each other since the speed of light (c²) is constant. Thus, a small amount of mass can generate a large amount of energy and vice versa. Who is to say that this energy within us does not transcend from one universe into another? Or pass on to the closest of kin? Indeed, do we not feel the energy, the life of the dead person, within us? I believe that after the death of my young wife, I was no longer the person I was before. I became a different person incorporating within me her energy. In my view, this was not a concerted effort on my part, but rather a spontaneous phenomenon without thought or intention. Thus, I believe that the very thought, the idea of a dead loved one: a wife, to a husband, or vice-versa, a parent to a child, lives within our minds as the very source of our own new amalgamated energy.

One can plausibly argue that there is no such thing as a soul or spirit as separate entities; that the very soul or spirit resides in our brain as a conglomeration of a host of neuro-hormones and neural transmitters that makes us feel and appreciate beauty, spirituality, a sense of transcendence though chemical interactions.

However, any such chemical interactions are, after all, a source of mass and energy.

There are possibly an infinite number of universes, and everything that can possibly happen occurs in some universe. All possible universes exist at the same time, regardless of what really happens in any of them. In this regard, space and time are limitless. In Einstein’s theory of relativity, there is no such thing as time in the singular. Time passes differently for different observers depending on motion. Time slows down substantially, and with it the aging process when travelling into space and at the speed of light. When Einstein’s old friend Besso died, he lamented that Besso had departed from this world a little ahead of him. That means nothing, he thought. “People like us…know that the distinction between past, present, and future is only a stubbornly persistent illusion.” Thus, immortality does not mean a perpetual existence in time without end, but rather resides outside of time altogether. This spiritual energy within us, the soul, the atman, whatever you may want to call it, exists within us, around us, since the past, present and future, or what we call space and time, could be but timeless illusions.

Undoubtedly, science has come a long way in understanding the physical nature of the human body, but our understanding of the human brain, the thinking process, such lofty and abstract attributes like spirituality, clairvoyance, the soul, and the presence or recognition of alternate parallel universes is lacking profoundly. It is possible that life continues as forms of energy in a parallel universe—some solace to the living and dying in these tragic times.

[1] Ammirati F, Colivicchi F, Di Battista G et al: Electroencephalographic Correlates of Vasovagal Syncope Induced by Head-Up Tilt Testing. Stroke, 1998; 29: 2347-2351.

[2] Moss J, Rockoff M: EEG Monitoring During Cardiac Arrest and Resuscitation. Journal of American Medical Association. 1980; 244: 2750-2751.