Making Sense with Sam Harris - #297 — Preparing for the End

Episode Date: September 23, 2022

Sam Harris speaks with BJ Miller and Shoshana Berger about preparing for death. They discuss the difference between palliative care and hospice, the tension between getting the most out of life and not clinging to experience, planning for death while still healthy, the importance of an advance directive, navigating the healthcare system, pain control at the end of life, assisted suicide, psychedelic therapy for end-of-life anxiety, and other topics. If the Making Sense podcast logo in your player is BLACK, you can SUBSCRIBE to gain access to all full-length episodes at samharris.org/subscribe.   Learning how to train your mind is the single greatest investment you can make in life. That’s why Sam Harris created the Waking Up app. From rational mindfulness practice to lessons on some of life’s most important topics, join Sam as he demystifies the practice of meditation and explores the theory behind it.

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Okay, well, this week is the fourth anniversary over at Waking Up, and I wanted to share a bit more about why I've decided to put so much attention over there and to build the app in the first place. Seems to me that many of you in the Making Sense audience don't necessarily understand what I'm doing over there. It seems to me that many of you in the Making Sense audience don't necessarily understand what I'm doing over there. When I was a teenager, after two people very close to me died, I became interested in certain esoteric questions. Like, what is the nature of consciousness? And what is a self? And what's the connection between the human mind and reality in the first place?

How is it possible to understand reality? And how should our answers to such questions inform how we live? Now, these topics didn't just interest me philosophically or scientifically. I wanted to explore them directly through first-hand experience, which is to say I wasn't looking to merely know more or to believe new things. I wanted to live differently. And all of this culminated for me after my sophomore year in college, when I dropped out of school for what amounted to a full decade.

This was the late 80s and 90s. And during that time, I made many trips to India and Nepal, where I got a chance to study with some of the greatest meditation teachers alive at that point. And I spent about two years on silent retreats, ranging in length from one week to three months. I also read very widely in the literature of philosophy and religion and contemplative spirituality, both from the East and the West. I also took psychedelics occasionally, more so in the beginning, and all of this served to fundamentally change my perspective on what was possible for minds like ours. So I came out of these years of seeking a very different person, and in many ways I found

the experiential answers I had been looking for. But none of this amounted to making viable contact with the world, much less a career. So eventually I went back to school, where perhaps unsurprisingly I majored in philosophy. And because I was still fascinated by the core questions of the mind and its connection to reality at large, I then did a PhD in neuroscience. However, just as I was beginning my doctoral research, studying belief, disbelief, and uncertainty using functional magnetic resonance imaging, September 11th happened. And because I had spent the previous decade deeply immersed in religious literature, my concerns about the threat of fundamentalism were already very well formed. It really didn't take me more than 24 hours to figure out what we were dealing with and to anticipate how confused many smart people would be by the problem of jihadism. The truth is many are still confused by it. So I stepped away

from my research at that point and published two books, The End of Faith and then Letter to a Christian Nation, which dealt with the Christian backlash to the end of faith. In both of these books, I argue that faith and reason really are in conflict, and that religion and science, therefore, are in perennial conflict. And together with the biologist Richard Dawkins, and the philosopher Daniel Dennett, and the writer Christopher Hitchens, I became known as a new atheist, and as one of the four horsemen of a new wave of opposition to organized religion. And all of this took some years to play out, and the resulting skirmishes in the culture war kept me away from my research for nearly four years. However, I've always been truly bored by politics, and most interested in those first questions that sent me to Asia

and into the silence of retreat. These questions about consciousness and the self and the nature of reality, whether we can know what is real, ultimately, for me, these are not divorced from everyday concerns. In fact, they directly relate to the most fundamental causes of human happiness and suffering, and to the larger question of what it means to live a good life. And ironically, they keep bringing me back to politics, which happens a fair amount on this podcast. My main concern at this point is to figure out how we can all live together so as to maximize the chance that humanity will thrive, now and in the future. So while

Waking Up is often described as a meditation app, its purpose isn't just to help you meditate. It's to help you live a more examined and fulfilling life altogether. The point is to help you close the gap between the person you want to be and the person you seem to be in this moment. Now, like this podcast, Waking Up is run as a subscription business. However, also like this podcast, we've always provided free membership to anyone who can't afford it. You need only send an email to support at wakingup.com to receive a free year on the app. And this can be repeated as many times as one needs. Our business philosophy is pretty simple. Of course, we want to grow as a company and build wonderful things,

but we never want money to be the reason why someone can't benefit from our work. We also give a minimum of 10% of our profits to the most effective charities, and this commitment to reducing suffering on other fronts has been central to our mission from the beginning. Now, perhaps you've tried meditation before and decided it's not for you, or you think all this talk about the nature of mind and the illusoriness of the self is just new age mumbo-jumbo. Well, okay. But if you leave it there, you really are shirking the challenge I'm posing to you. Because my claim is that you have spent most of your life

lost in thought. That is, thinking without recognizing thought itself as a process, and therefore not recognizing what the mind is like prior to identification with thought. And this status quo is the basis of all of your suffering. It's the mechanism by which disappointment and worry and regret and anger and sadness color your life. It's the thing that makes you bad company for others and for the important people in your life whom you ostensibly love. It's what makes you an asshole when you are an asshole. And you are extraordinarily likely to spend the rest of your life in this condition, unless you look into the matter deeply. And it's over at waking up that I most fully explore this terrain. So yet another pitch from me to look into it, if you haven't. And as chance would

have it, today's conversation is about death and how to prepare for it in practical terms. Now, death is something I've thought a lot about. I've always had a sense that I think about it more than most people, certainly more than most people I know. I lost one of my best friends when I was 13, and my father died when I was 17. I don't think this is an unusual amount of exposure to death, but for some reason these losses were very formative for me. For as long as I can remember, certainly since I was 13, I've thought about death many times a day. Some of this thinking may have been morbid, but much of it's been useful. Though I can't say I haven't wasted time, I don't have any important regrets at this point.

In the last few years, I've been keenly aware that I've outlived my father. He died at 51. keenly aware that I've outlived my father. He died at 51. And I've often recalled what it was like for him to live his last year of a life interrupted by sickness and death. When I read or listen to authors or philosophers or scientists who I admire, I notice which ones are dead, and I notice what age they were when they lived their last day of life. And when I hear or read one of them say something about the future, I occasionally do a quick bit of math and realize this was a future they never lived to see. I enjoy old films and photographs, but not merely for what their creators intended. I also view them as rather vivid obituaries to the people in them. So more

and more I live with a sense of the finiteness of life, and it's making me wiser, I think. I mean, we work and travel and eat and sleep and dream, and we repeat these things as though we might live forever, and yet one day we will die. There is something astonishing about this. I really don't think I'm afraid to die, though perhaps I'm afraid of the chaos and pain and indignity that might surround the process of dying. But as to the ultimate experience of finally surrendering my life in the world, I don't actually worry about that. And again, I would credit my experience with meditation and also with psychedelics for that. I do believe it's possible to run the loss of everything in emulation mode before it actually happens. You might see my description of what it was like to take five grams of mushrooms

for more color there. However, losing the people I love is something that worries me. Paradoxically, it doesn't worry me that I will lose everyone when I die. I just worry that I could lose some very important people while I still have many years yet to live. And I'm also aware that I have at least a few people in my life who are very worried about losing me. So anticipated sorrow haunts our living. We know we're going to lose people, and we know that others we love will lose us. We know, therefore, we will be givers and receivers of grief.

What a strange situation. So much of my interest in meditation derives from this. How can we live truly fulfilling lives in light of death? How can we prepare our minds to lose everything? Well, among other things, by learning what it means to not hold on to anything. What is it like to have a mind that doesn't cling to memories, or to hopes for the future, or to experience itself? That is really the essence of meditation. Meditation isn't, in the end, a practice you add to your life. It is the discovery of what it means to not cling to experience,

to identity, to a concept of a self. What is that experience like? It's doing less rather than more. experience like. It's doing less rather than more. It is ceasing to do something you're doing by tendency right now. And if you can't find that experience of freedom now, it seems very unlikely that you'll find it later, amid the great unraveling at the end of life. Anyway, today's conversation is a very practical discussion about the unavoidable fact that life ends. Either you will die and others will have to deal with the aftermath, or you will live long enough to have to deal with the deaths of the people you love, and then you will die. And there really is a fair amount of practical wisdom that can help you

navigate this process. Today I'm speaking with B.J. Miller and Shoshana Berger, and they've written a very compassionate and useful book, A Beginner's Guide to the End, Practical Advice for Living Life and Facing Death. And as I emphasized several times in this conversation, the conversation really isn't a surrogate for reading the book, because there is a fair amount of practical advice to give here. B.J. Miller is a hospice and palliative medicine physician who's worked in many different settings, and he now sees patients and families at the UCSF Helen Diller Family Comprehensive Cancer Center. He speaks all over

the country and internationally on the theme of living well in the face of death, and he's been profiled in the New York Times and elsewhere. Shoshana Berger is the editorial director of IDEO, and she was a senior editor at Wired. She's written for the New York Times, Fast Company, Time, Wired, Popular Science, and other journals. She's also the author of another book, Readymade, How to Make Almost Everything. And today we talk about preparing for death. We discuss the difference between palliative care and hospice, the tension between getting the most out of life and not clinging to experience. We talk about planning for death while still healthy, the importance of an advanced directive, navigating the health care

system, pain control at the end of life, assisted suicide, psychedelic therapy for end-of-life anxiety, and other topics. Again, this is a subject you might not want to think about, but I'm convinced you'll be better off if you do. And now I bring you B.J. Miller and Shoshana Berger. I am here with B.J. Miller and Shoshana Berger. B.J., Shoshana, thanks for joining me. Thanks for having us, Sam. Thanks for having us, Sam. So you have written a wonderfully useful book together, A Beginner's Guide to the End, Practical Advice for Living Life and Facing Death. But it will not be without trepidation

that most people pick up such a volume. And I want us to just get into really everything relevant here. I mean, there's no way this conversation will be a surrogate for reading your book because your book is filled with practical advice that really is better read than listened to in terms of the kind of, you know, checklist advice one can have for people facing terminal illness or going through the experience of having a loved one face it. So we'll touch on some of that and anything that seems super important, feel free to interject it, but it's just a note to listeners that there's more in the book of practical significance than we will cover here. But before we jump into the topic, perhaps each of you can tell me how you came to focus on death and dying professionally to this degree. Most people

think about death, but you two have gone all in. Maybe BJ, we can start with you. How did you come to this topic? Yeah, a couple different ways, Sam. Well, I don't know, personally, professionally, it kind of came, kind of co-evolved. For me, a lot of it starts with my own injuries when I was 19, sophomore in college. That's when I came very close to death myself. And that was a real wake-up call, as you can imagine, to take life seriously, but also playfully, but really get into this thing while I have it. It might be worth telling that story however briefly you want to, because people might imagine that you were playing football and got a concussion or something more prosaic, but you had a fairly spectacular encounter with mortality or near mortality. I did, but I'm chuckling because you reminded me of a moment at a restaurant

long ago when I was wearing shorts. I'm a triple amputee, guys. I'll tell that story in a second, but a very sweet, ancient woman approached me in a restaurant and tapped me on the shoulder and said, football injury? I didn't know how to answer that. But anyway, so yeah, when I was 19, I was just horsing around with friends and there was a parked commuter train just on the edge of campus sitting there, not moving, not just sitting there. And we decided to climb it like you'd climb a tree, just kind of being sophomores, sophomoric. And the power lines run overhead. And when I stood up,

I had a metal watch on my left wrist and the electricity arced to the watch, and a big explosion. I was in and out of, I was close to death in the burn unit there in New Jersey for maybe six weeks or so, in there a total of three months or so, but survived, hello, but ended up losing both legs below the knee and my left arm below the elbow. So yeah, it was a pretty spectacular moment that was a real, you can imagine, real crossroads in my life that led me into medicine and an interest in life that included death, an interest in life that included loss and suffering, as well as joys and immutability and change. So that was very much my entree. That took me into medicine. At first, I was going to do rehab medicine. Disability was the thing that I kind of walked

away most interested in. What do human beings do when they bump up against things they can't change or can't control? And that was really the nugget for me. And from there, it was also entwined with death. But as I kind of got into it more and more, suffering death, wanting to change, not wanting to change, that whole stew kind of begat palliative medicine that took me into hospice and palliative medicine. And from there, death became front and center with a lot of the hospice work. But even for patients who had plenty of life left, I was noticing that death, either metaphorical death or physical death, it could be this great prompt, this great foil.

And so that is what I really began to work with it professionally to mirror what I was doing personally. So anyway, I don't know how short that was, but that's the gist of how I got into this subject. And Shoshana, how did you come to this? So it started as a very personal issue for me. I'd had a lot of exposure to death pretty early on in life. My college roommate OD'd, and I've had actually two boyfriends die of the same cancer, which is very odd. And then the kind of critical death for me was my father's death. And I met BJ just after that, and that's when it became professional. So we actually met at IDEO, the global design company where I work. At the time, BJ was the executive director of the Zen Hospice, which is this beautiful residential hospice located.

It used to be located in a Victorian house in San Francisco where people came for comfort and care at the end of life. And as you may know, Sam, hospice carries an unfortunate stigma. Many people actually consider it to be a kind of death sentence. So BJ and his team came to IDEO hoping we could find a creative way to recast or effectively rebrand hospice in a way that would communicate its value because it's really the most holistic, palliative, and free suite of care you can opt for at the end of life. And so when the designers at IDEO caught wind that we'd be working on designing the end of life experience, they were so excited about working on something

that was so consequential and so poorly designed in American culture, largely because we live in denial of our own mortality and do everything we can to avoid thinking about it. So this idea of designing quite literally life and death was extremely exciting and everyone wanted to work on it. Designers were throwing themselves into the volcano. And I ended up on a small team. We created this kickoff meeting to invite BJ in, where we actually built this tunnel that led from our office entrance on the pier at the bay in San Francisco to this dome-like structure, built to fit a small group just sitting in the round. And internally, that meeting space became known as

the death yurt. And on that first day when we met BJ, we led him in through this kind of liminal tunnel, this passageway that terminated in this candlelit dome. And it had a transparent top and it caught the flickering shadows of the candlelight. And we just wanted to create an intimate, safe inner sanctum for this conversation. There were 10 of us there and our assignment was to come ready to talk about how we design our final moments on earth. So we started going around the room and each person painted a more opulent picture than the last of what their final moments might look like. I mean, alone at the top of a mountain or being surrounded by all your friends and family,

but in a forest or assembling your perfect curated death playlist. And I remember I was dreading my turn because I was fresh off of my father's death just three months before, and I had just started at IDEO, and I wanted to join this rapture, but I'd witnessed my father's death as something so quiet and something that didn't remotely resemble any of these lofty visions. I mean, my father suffered with dementia and depression for many years, and he did not have an easy death. And by the time we got him on hospice, he was mostly unconscious. He hadn't uttered an intelligible word for a year. And my last moments with him were, you know, as I would imagine many last moments with loved ones are,

just very quietly by the bedside stroking his forehead and wetting his lips with a sponge and whispering that I loved him and scrambling to find a CD of Yiddish music because I knew those were the beloved songs of his childhood and that, you know, hearing is the last sense that you lose, hoping that he would hear that. So anyway, I was trying to square my experience with this exercise that we designed for kicking off this work with BJ and this hospice. But my father's experience felt so undesigned and so over-medicalized and in many ways, quite inhumane. And so when my turn came, I just said as much and I broke into tears. And I remember BJ was sitting across the room from me and locked eyes with me. And I knew that he understood as a palliative care physician whose work is to usher

people through this human condition of suffering. He knew that that's what death looks like, and it looks nothing like what we see on TV. And it often happens in an ICU and in a clinical setting. So anyway, I came to understand that designing one's life and death doesn't mean that you can really control it. It means that you can come up with some principles for how to be true to how you want to live. Well, so you've introduced a couple of terms here and also a stigma associated with one of them. Perhaps we can explain this state of affairs. So, BJ, can you differentiate palliative care from hospice? And either one of you can tell us why there is such a gravity to invoking hospice care and how we should

think about that. Yeah, sure. And Shosh, maybe I'll define some of these things and yeah, I'll leave it to you to help us understand how they land with the public we've been wrestling with. I mean, palliative care, it gets so confusing, Sam, and I really appreciate your question. I mean, people within medicine get confused about what the heck palliative care is. It's really important. So hospice came first. It's an ancient idea, really took off in modern terms in the UK

in the 60s, came to the US in the 70s and 80s as a sort of a non-medical, largely volunteer approach to care. And it was very beautiful. And in the 80s, Medicare got in the business and started paying for it in a novel way. And you tell me, Sam, we can take any little tributaries on policy fronts or whatever else along the way here. But since the 80s, hospice became an insurance benefit. So that's how we say we're on hospice. We're on the insurance benefit called hospice. So hospice has many meanings, but it is this kind of care reserve for the final six months or a year of life, say. But into the 80s and 90s, people who did this kind of work one way or another would kind of realize, well, why are we waiting till the end of people's lives to listen to them,

to defer to their experience, to honor them, to tend to their comfort, to their peace, help them make meaning, deal with meaninglessness, help the families reckon and square what's going on and live on. It's beautiful, beautiful stuff, but we reserved it for the final six months or less to live. So in the 90s, the idea was to try to break it free of the insurance designation, which is the thing that said six months or less to live, and you got to give up certain kinds of care to go on to hospice, all these kind of invented hurdles, man-made. And so in the 90s, the field of out-of-care grew up. The term was coined by Balfour Mount in Canada, who was one of the first hospice docs in North America. And we were trying to always evade the baggage of the hospice designation. And also it's sort of attachment to death because the whole idea is really to live well until you die. It's not about celebrating

death per se. It's really about celebrating life and eking out all that you can while you can. So out of care grew up in the 90s as a field to say, no, no, our work here is multiple disciplines coming together to mitigate suffering, essentially, to focus on the experience of illness, not the transactions of disease management, to help you suffer less and help you realize more joy. That's kind of the gist. So palliative care is now the umbrella term since 2006. The field at large is palliative care. Hospice now is considered a subset of palliative care, that is this kind of multidiscipline work, but still reserved for the final months of life. Whereas in palliative care, it's the same

training. You're a hospice doc as well as a palliative care doc. They come together. But in my palliative care clinic, I'll see people for many, many years or people who are in remission who aren't dying anytime soon. So sorry for the long answer, brother, but that's kind of hard to do succinctly. That's good. But is it true to say that hospice only gets triggered once you admit, you being the patient, the family, in concert with the healthcare provider, that you're no longer doing anything to fight this illness and attempt to overcome it? You're not deliberately prolonging life at that point. What is it that you are no longer doing in order to invoke hospice?

So that's right. So you're pointing to the two main stipulations of the hospice benefit to qualify for this kind of care to be paid for. Two things. Two doctors have to certify that your death will likely come in six months or less. We're pretty bad at prognosis, so it's a best guess. And the second stipulation is what you're pointing to is you have to essentially stop trying to combat this illness. So if you're dying from, say, heart failure, if that's your hospice diagnosis, you can come into hospice. We will stop a lot of these expensive heart pumps and things like that that are sustaining your life or trying to cure or reverse the heart disease. That care then goes into

instead making sure you're comfortable and working with you for the time that you have to realize certain things in your life, et cetera, becomes much more social, much more supportive, in a word, rather than trying to fight the disease, you're trying to support the person. So that's the kind of segue of care. Your other diagnoses, if you have diabetes and any other thing, that can continue to be treated. But the diagnosis that qualifies you for hospice, you no longer qualify to push back on that disease. And in the 80s, that made a lot of sense. By the time you reached this point, there wasn't much more to try to beat your disease, or by then the person was really not interested in this or that treatment. It was too taxing, too toxic. It's getting a little messy

now because a lot of treatments coming down the pike can help you live a little bit longer, a little bit more comfortably, but are not ever intended to say fix or cure your illness. So there's an increasing gray zone of treatments that might qualify from a palliative point of view, but don't from a hospice point of view for these reasons. So it gets really murky and it feeds into this, that hospice is giving up because in some way you are, you're giving some choices up. Does that make sense? Can you kind of picture that? So the question I posed about people's hesitation around invoking it sort of answers itself because it comes at the moment where you have to admit that, okay, you're going to die from this thing. And it's no longer a story of how you're going to

get better from the cancer or whatever it is. That's right. Shoshana, did you have something you wanted to say there? Well, I always look at the kind of etymology of these things, hospice and hospitals and hospitality. It's all about caregiving and how we care for people, how we care for each other through the entire arc of life. And we pay a lot of attention for how we care for our firstborn, for how we care for children, and very little for how we usher people out of life. And part of the project of this book was knowing that there was this book, What to Expect When You're Expecting, for new parents, which has sold like 500 million copies, and every set of parents gets their newly minted copy. We wanted to create

something like that, a stepwise approach to thinking about this experience for the other end of life. And hospice is a part of that. Yeah. So you mentioned, BJ, that you were at the Zen hospice. Does that suggest that you were a Zen practitioner before you came to it, or did you just come as a hospice doctor who happened to land at that particular hospice? No, I came there, more of the latter, Sam. I came there entranced by two things at Zen Hospice Project, which had started in 1987. And I know you've had a beautiful interview with Frank Ossiseski, who was the founding executive director back in the 80s. I mean, a really remarkable little place. And it had closed down after Frank left and it

was just reopening. And so I came there as a hospice doctor, as an agnostic hospice doctor who was broadly interested in spirituality or just philosophy, how we approach the truth, how we approach life. So I was interested in Buddhism and had studied it a little bit and found it irrefutable in so many ways. Didn't really see it as a religion, but more as a philosophy. And my agnosticism fit, I thought, pretty snugly within those confines. But I was really there as a hospice doc who loved architecture. And this sweet little guest house as Victorian was sort of anything but a nursing home, anything but a hospital.

And there was a sort of a belief or an observation that the bones of a place, the inanimate objects, the design, all of that could affect the experience. Of course it can. The beauty of a place, of course it can. So I was there for the house and I was there because they had a basis of care in volunteerism and in spirituality. And that seemed like a very interesting, perhaps a larger, better catchment for this subject than the sort of reductive medical model per se. Dr. Justin Marchegiani Shoshana, do you have a background in meditation or any spiritual practice that's informing your approach to this?

Dr. Shoshana Well, Sam, I largely learned to meditate from you. I have to give you credit here. Someone gifted me a subscription to waking up and I had dabbled in meditation before and growing up in the Bay Area, you can't help but like osmotically be exposed to all of the osmotically be exposed to all of the Buddhist activity around here. And we have spirit rock here. And so, I had a yoga practice and certainly I was interested, but really it wasn't until I started having you in my ear that I started more religiously meditating. But I'd just say that for me, the death of my father was such a tectonic shift for me. And it so rattled me to the core that I did turn to various different spiritual guides and faiths. I certainly turned back to my Jewish community and I listened to a lot of

very wise teachers who grapple with loss and death and grief in a way that I think is very useful. To me, the Tibetan practice of meditating on death five times a day, I think it is, is really right. It's that you should keep death close because of course, it is everywhere and we are dying all the time. And having that inform how you live, that has changed my life. That has brought more urgency to my life. It has brought much more connection, more presence. And so I think that's all very useful. Yeah. Yeah. Well, more or less every spiritual tradition recommends that we keep death in mind. And it's the impermanence of life that motivates most philosophical reflection or deliberate practice that's aimed at wisdom.

But it's always seemed to me that there's a paradox or a seeming paradox between the two modes of response to this reflection. I mean, there's the mode in which we can really seize the day with a sense of urgency and follow a sort of carpe diem piece of advice, which just alone can be a kind of just a further adumbration of our attachment to things and clinging to things. I mean, there's no bucket list, however fully accomplished, that's the same as recognizing a quality of mind that just doesn't cling to experience and to life itself. And so I think there's this potential trade-off and confusion between the urgency of trying to get the most out of life, which again, there's a lot to be said for that, but that's distinct between simply recognizing that this moment is already enough, right? And I think more and more we want, I mean, certainly anyone with a

meditation practice will find this familiar, we want a mind that is at peace with experience, whatever it is, and is at peace with the reality that we're at bottom, we're not really in control of anything. And it's these kind of nested illusions of control that we sort of fight our way beyond as we confront our and others' mortality. So I'm wondering if either of you have any reaction to that, because in my own life, I noticed that I really am running both programs. I mean, there are many things I do because I want to do them, and I have vacations planned and projects planned, and there is a sort of bucket list mode of prioritizing things that, you know, on their face seem like good and enjoyable uses of time. And I wouldn't

say that that is a waste of time, but if you are living with the illusion that your happiness is going to be secured, you know, only when you arrive at the peak of all these mountains that you're planning to climb. You seem guaranteed to be disappointed. And there's sort of a figure ground reversal that needs to be accomplished where you can recognize, well, it's possible to be already happy before anything happens, before the vacation actually arrives. before anything happens, before the vacation actually arrives. It's only worked out for me in continually kind of being buffeted back and forth between those two modes and recognizing that one needs to supersede the other for me. Yeah, Sam, you're really putting something really important here. And I think in some ways, Shosha and I, the book in some ways as a beginner's

treatise, we mostly suggest or come up to find our way to, oh boy, okay, time is finite. My time is finite on this planet. And okay, let's take life seriously. Let's let it distill what we care about and let's pursue those things that we care about. There's something really beautiful and wonderful about that. One of the things, if we were going to write an intermediate guide, I think we'd spend more time on a second book, squaring the limits of that approach along with the limits of the self. And if you just stay in yourself all the time, you're only going to get so far. That would probably be the sort of second big book. But you're right on. I think as I've kind of gone down this road myself or in my work, I am increasingly tuned into,

and it's always a dynamic, just as you're saying, Sam, of this other piece of learning to be okay with what already is. Front preload your happiness or your peace and then work from there. Don't this idea of hedging, leveraging your current peace for some better peace or more happiness down the road. I used to do this a lot with myself and I do it less and less to leveraging the present for some possible future. And so I think what you're pointing to is just perfect, Sam. It's really not one or the other. It's not being or doing. It's really, I think the project ends up being cultivating the good judgment to pull on the right tool and to not see these as a dichotomy. It's not being versus doing. It's not caring about achievement versus whatever. And to not see these as a dichotomy, it's not being versus doing. It's not caring about achievement versus what... These are false divides. You can do both. And I think over time,

what you really, a mature person gets to is this sense of judgment, of toggling between the two, applying these approaches and these mindsets at the right time and holding it all loosely, leaving room for things that you just don't understand. So there's some perhaps like a unifying theory out there that we haven't kind of hit on just yet, but you move between these valences and that's where so much of the action is. That's where you stay really, I think, very present with yourself in real time. You can square the expectations of yourself and from others of you and of your life and the potential you have to make something with it with the idea that it's never going to be enough if

you're really paying attention. There's always more. It's always a work in progress. So yeah, I don't know that I'm saying anything novel there, Sam. I think you spelled that perfectly, but that so much really is, as far as I can see, is the project. Yeah. Yeah. Well, just the being, doing opposition lends itself to being while doing, right? I mean, really you can run those two together. Yep. Yeah. Yeah. There's that great phrase, life is what happens while you're planning that vacation, right? I mean, we tend to live in any tense but the present. We live in the past and feel regret. We are planning for the future.

I remember there's, I don't know if you ever saw that movie Nomadland. Oh, no, no. Oh, it's this wonderful movie with Frances McDormand. But there's a story. It's basically about people who hit the road in vans and are unhoused and just travel through life. And there's one scene in which they're all sitting around the fire at night in essentially the trailer park and telling stories of why they became nomads. And one woman says, you know, I was working in the corporate world for 20 years and my boss saved up for a boat, which he had parked in his driveway. boat, which he had parked in his driveway. And he kept saying, I can't wait to retire and take this boat out and just set sail. And everything was dreaming about this future, this imagined

future happiness that he was in pursuit of. And then of course, he got a terminal diagnosis while still at work and a very short window of time. And that boat never left the driveway. And she says that was the moment that catalyzed her. And she was like, that's my life. I'm not waiting for my life to start. I'm going to start it now. And she got in the van and rode off into the sunset. And I think there's so much wisdom in so much of the conversations you have about this, about that illusory pursuit of some future happiness when really the moment that we have now is the most is the most voluminous opportunity we have for that. And I have to say there was a lot of lessons about that in caregiving for me. So when I was taking care of my father,

I really had to investigate the nature of time in a different way. I had to really synchronize to his time, which was very slow, a much slower metabolic rate than I'm certainly used to. I'm a really busy, full-time working person with two teenagers. And we mostly live in chronos, that linear clock time of which there's never enough, right? The stoic philosopher Seneca writes about the shortness of life, and he postulates that it feels long if you know how to live it, that you can, if you find length in those moments, time can be elastic and can expand and contract depending on how we inhabit it. So you can either be kind of ravaged by chronos and linear time, and it can become very transactional. We have all these phrases about that time is money and you're wasting time, time waits for no one. But, you know, when you are caregiving, you really have to slow time down and just be there.

And there are real depths to plum I found there. You know, I would often just end up sitting on the couch with my father holding hands. And there was a universe of feeling there that I really hadn't had with my father before because we had had a very heady kind of relationship that was really built on the commerce of ideas and just conversation. And suddenly he had no use for language, no use for hearing about my life and my accomplishments, but just sitting and being with him and watching my kids play became this shift in how you inhabit time and feel time. And it's like there's that phrase, don't just sit there, do something, which gets inverted in the most lovely way when you're taking care of someone who needs quiet, and it turns into don't just do something, sit there. Yeah. So, okay, so we can, we're really talking about both sides of this,

but I think it's useful to acknowledge how different they are, even though they both come to mind when we talk about death. And there's the difference between being the one dying and being among the bereaved or soon to be bereaved. And they're just, they're very different experiences. Obviously, I can only talk about one of them, but BJ, you have seen both for years and years, and I can imagine you've seen hundreds, if not thousands of people die, and that many families and circles of friends go through the bereavement process. I think we should cover any side of it you want to, but perhaps we can start with, and this is sort of where your book starts, with advice for healthy people for whom death is still fairly hypothetical, right? I mean,

they may have had someone close to them die at some point, but they're not dealing with it now, and life is, quote, normal, and you haven't been dragged into the kingdom of mortality, which happens the moment your day is now going to be spent at a hospital, whether for your own illness or the illness of someone you love. So let's talk about normal life. What do you both advise people to do now? Well, so maybe I'll set us up here, if that's all right, and then we can play together on this one too. I mean, I think a couple of thoughts. One is just to get to the pretext of your question, Sam. Yeah, you could very easily and well make the argument, when do we begin dying? They were born somewhere after our brains

stopped developing, if they ever do. pick a... But that's an evasive answer. There is something different about when your horizon is in sight, when you know the thing that's going to end your life. It's more of a spectrum as you move from abstraction to reality. But there are meaningful differences from someone who's at the end stages of an illness and dying at any moment from someone who's walking around talking and otherwise in good health per se, et cetera. So your question alone brings up a lot of good points, but let's just hold that there's a difference between sort of the acute or near-term dying

phase and the rest of life. And you see that in the body. You know, one of our chapters is on final days when things, rules of thumb that guide you through the rest of life no longer really apply. You know, food and water goes from something of sustenance to something that actually can hurt you, for example. So there's some other examples in the world of physiology. But let's take, so that's all behind your question, but let's get to your question.

So one of the reasons why, and by the way, let's give Shosham credit. It was her idea to write this book, and it was a terrifying prospect, but we both, it was an easy thing for me to say yes to because we both knew there were some basic things that could be covered and we could level set for our readers and avoid a lot of unnecessary suffering. And it was also a joy to write with Josh in so many ways as a lay person, as a caregiver, as a design thinker, not as a clinician. So just wanted to get that out there too. And I'll cut to you, Shoshana, in a second, because a lot of your work was some of those early chapters. But just to say, the reasons to write a book like this, the reasons to read a book like this are because while you're early in life,

the thesis is don't wait until that diagnosis to realize you're mortal. If you can, invite the truth of death into your life earlier and you'll receive its lessons. And on practical terms, there are some things any of us can do early in life that will prepare us for our eventual death in some real practical ways. So one thing to realize is our healthcare system, the default settings of the healthcare system are to put you on machines, take you to ICU, do everything humanly possible to keep your heart beating. And in the world of medicine, again, a very reductive, very powerful, but very reductive lens onto life basically holds that if you got a heartbeat, you're alive, essentially. Some brain activity, you're alive. Most of us wouldn't consider that living by some definition, but that's the healthcare definition. So if you don't do, say, an advanced directive,

you run the risk of just falling down the default path of medicine and ending up in the situations you probably don't want to be in or you might not want to be in. So there's a big reason to think about it so you can get the sort of death that suits you. Another reason, of course, is to prepare for it so that it's kind of one of the kindest things you can do for your family and friends, people who will live on after you. If you've stated your wishes, if you've made it clear how you want to go out, then you take so much guesswork out of the people who will survive you and you can ease their grief. But the third reason to do all this stuff, I think it's the best or the biggest or something like that, is what we've touched on. Once you

realize you will die at some point, you, in a sense, can start really living. And I have seen that play out a zillion times over in my own life and in others. And so that's the setup. That's why prepare. Otherwise, gosh, you just say, people have been dying forever. It's a natural thing. When my turn to die, I'll die and I'll be fine. Why do I need a book to tell us about this? Well, we need a book to tell us about this because we've invented structures and systems that make certain inevitabilities in life a little inhospitable and shaky and counterintuitive. So anyway, over to you, Shosh, maybe on some of the advanced planning and other things. Sure. Well, I just want to make sure we're answering your question here, Sam. Is that

really it about how you prepare yourself for this experience and think about it further upstream? Yeah. I think it's natural for people who are healthy and for whom nothing bad on this front has happened yet to want to use that time to think about everything other than planning for the inevitable. Even if they could pay lip service to the understanding that it is inevitable, it's just, you know, there are many people who don't have wills. And even if you have a will, that really doesn't quite get at every aspect of planning you deal with in your book. And again, the checklist aspect of this, I think, is best delivered by your book, not so much by audio. But I think some of the big

points are worth talking about. For instance, the advanced directive, I love your take on it as well, Shoshana, but I'm also wondering if the physician's eye view of death, having seen many, many people die, could give us some wisdom as to what's worth wanting with respect to resuscitation or not, etc. with respect to resuscitation or not, et cetera. Well, I'm definitely going to hand that one over to BJ, but I'll just say from my perspective in writing the book and talking to hundreds of people about how to kind of grapple with this experience, it's so taboo in our culture. And you're absolutely right. We don't want to think about it. We don't talk about it. We don't have conversations about it. We have a colleague, Jessica Zitter, who is a palliative care doc and an ER doc. And she actually wants to institute death ed in schools as a component of, you know, or as a counterpart to sex ed. or as a counterpart to sex ed, because we really do think that it should be just a conversation that we have throughout life. And there are so many different touch points throughout life when

it's appropriate. Like when your kid goes and becomes a driver and takes his driver's test or her driver test and has to choose whether or not they want to become an organ donor, great opportunity to start talking about, yes, there's a possibility that when you get behind that wheel, you will get in an accident. And let's think about what you might offer the world in a very generous way if that happens. So there's so many opening gambits throughout life when you can have this conversation. But I'll just say that there are a lot so many opening gambits throughout life when you can have this conversation but i'll just say that there are a couple of different things we talk about in the book and one is the kind of material mess that we accumulate in life and how to deal with that because of course

you hand all of that down to the people who you love. And it's a lot. And there's this great Swedish notion of death cleaning that as you get older, you should go through your material world and decide what you need and what you can give up because you don't want to pass that along. You don't want to pass that mess along. It's a lot to get through for the people you love. And then there's, of course, the emotional mess that we create in life as human beings, which is much more complicated. But that is where the meat is, is thinking about your relationships and whether or not you have resolved old disputes, people in your life, what do they need to hear from you? How are you feeding and watering your relationships throughout life? And Ira Bayak, another palliative care physician who we interviewed for this book,

has this beautiful framework of saying the four things that matter most at the end of life. And those things are, please forgive me, I forgive you, thank you, and I love you. And he says that just saying those things can really unburden the people around you in feeling like they've come to terms with letting you go and feeling resolved about that. And we actually asked him, Ira, it's been 10 years since you wrote that book, is there anything else you'd add to that list? And he said, actually, I talked to 60-year-old men who are still carrying around the wish that their dead fathers had said to them, I'm so proud of you. And so I've really built that into the way that I raise my kids, just taking every opportunity to tell them how proud of them I am. And I think we just, again, just returning to this moment is the only moment that

we can be sure of, knowing that you are expressing the things that you need to express. And then all the paperwork stuff, you're right, Sam, we cover off in the book. We actually have this notion of a when I die file, which has like 20 things in it that you want to put in there. And that can be in a shoebox or a file or on the cloud, wherever. But it's a place where your family can go to find all of the logistical stuff that just traps people up when they're in the thick of grief and they can't even think straight. And they just need very clear instructions for how to shut down a life. BJ, before you give us the DNR particulars, I forget if you mentioned this in the book,

do we know the statistics on just what percentage of people die suddenly and bypass any need for advice around how to navigate a terminal illness? I mean, they're just, I guess this is more or less, you know, cardiac events and accidents we're talking about here, but do we know what the percentages are? The data that I've seen referenced, I have to say, I haven't chased it down to its source. But the data I've seen referenced around your question, Sam, and it mirrors my own experience and my practice, but maybe 10% to 20% of people can look forward to that spontaneous death where they're fully alive one moment and then whammo, gone.

And there's not much in between space. And that number is shrinking in part due to the advances of medicine. We're able to keep people alive. Myself is one of them. We can keep folks alive, but not unscathed. And so a lot of people now, a lot of illnesses that were immediately terminal nowadays are chronic, at least for many years. So another thing that the book steps into or our time steps into is this moment where science and medical science has

advanced and it's smeared or protracted this dying phase. And that has lots of consequences. So for good and for ill, we live with this thing that will cause our death oftentimes for many years. And so more and more of us are dying from chronic illness. That will very likely, it is right now very likely the reason the way you or I will die, and that number is growing as the population ages. So these issues are becoming more and more important or powerful, and in the coming decades they will continue to swell. Aging, dying is going to be increasingly in our face because of the population dynamics.

Yeah, yeah. face because of the population dynamics. So with that, another sort of reason to pay attention to this stuff now. And as Shosh, as you're talking, I'm reminded too of one of the joys of this work that we did together or do together. There's also just the magic like you're doing with us today, Sam, of just talking about these things. And you have done such a beautiful job before us too. I mean, this subject is not a stranger on your work, and that's beautiful. It's just the basic math of pulling things out of a closet. And one thing I kind of want to get out there,

I'm going around here non-linearly, but as you were referencing a moment ago about, there are some important differences between living and dying. I'll just say, I'll jump to what feels to me like really good news and a good news observation in a lot of this is that a lot of what feel like neurosing around regret and getting it right and learning how to heed or pay attention or quiet our critic and all the things that we kind of frantically do to ourselves and to each other when we have this sort of open-ended life in front of us. In some ways, that's the hard part.

But by the time someone is actually dying in their final days and weeks, and they've gotten a taste of watching their body fall apart bit by bit, and dying in some ways has already begun, they've already said a lot of goodbyes. When you're kind of shaken down by that chronic process, one of the things that often goes, especially if you have some loving support around you, I don't hear a lot of people in their deathbeds wailing about regrets, actually. I hear a lot of folks at the time of diagnosis wailing about regret. That's an important difference. So I just want to kind of note that.

There's some good news here that I think in some ways, living is the harder part or some ways more complicated. Dying can really bring us down to the essentials and distill life and make it very obvious in some ways more complicated. Dying can really bring us down to the essentials and distill life and make it very obvious in some ways. So let that be good news. That's interesting. Meanwhile- I mean, I've actually never heard that point made and it seems intuitively right. Do you have an explanation for it?

Well, I don't per se, but not a scientific one. explanation for it? Well, I don't per se that not a scientific one. If you'd like to continue listening to this conversation, you'll need to subscribe at SamHarris.org. Once you do, you'll get access to all full-length episodes of the Making Sense podcast, along with other

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