EP. 42: LIFE LESSONS FROM DEATH
WITH FRANK OSTASESKI
A Buddhist teacher and pioneer in end-of-life care shares how maintaining an ever-present consciousness of death can help us live life more fully.
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Episode Summary
"Death is not waiting for us at the end of a long road. Death is always with us, in the marrow of every passing moment. She is the secret teacher hiding in plain sight, helping us to discover what matters most."
So writes Frank Ostaseski, an internationally respected Buddhist teacher and pioneer in end-of-life care. Frank is the founder of the Zen Hospice Project in San Francisco, the first Buddhist hospice in America. Over the course of his career, Frank has accompanied over 1000 people through the dying process; these experiences have taught him lessons on how maintaining an ever-present consciousness of death can bring us closer to our most authentic selves. He describes these lessons in his bestselling 2017 book, The Five Invitations. In this episode, Frank joins us to share hard-earned wisdom from his unique life journey. Over the course of our deeply reflective and even meditative conversation, we discuss matters ranging from Japanese death poems, to Buddhist mindfulness practices, to what courage looks like in the face of death.
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Frank Ostaseski is an internationally respected Buddhist teacher and visionary cofounder of the Zen Hospice Project, and founder of the Metta Institute. He has lectured at Harvard Medical School, the Mayo Clinic, leading corporations like Google and Apple Inc., and teaches at major spiritual centers around the globe. Frank is the 2018 recipient of the prestigious Humanities Award from the American Academy of Hospice and Palliative Medicine.
He has accompanied over 1000 people through the dying process and trained thousands of healthcare clinicians and family caregivers around the world. His groundbreaking work has been featured on the Bill Moyers PBS series On Our Own Terms, highlighted on The Oprah Winfrey Show, and honored by H.H. the Dalai Lama. He is the author of The Five Invitations: Discovering What Death Can Teach Us About Living Fully.
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In this episode, you will hear about:
• How the AIDS crisis led to the founding of the Zen Hospice Project - 2:16
• What Frank’s work looks like on a daily basis - 3:52
• Frank’s role as an ‘interpreter’ between patients and doctors - 5:57
• How clinicians can develop their own rituals in the process of healing patients - 9:09
• How Frank makes sense of the grief and suffering he witnesses and, despite it all, keep his spirit balanced - 13:40
• How the tenets of Buddhism influenced care at the Zen Hospice Project - 25:58
• How progresses in modern medicine sometimes hinders us in our acceptance of the impermanence and inevitability of death - 33:56
• Lessons on love, mindfulness, and finding meaning from Frank’s stories of patients at the end of life - 38:20
• The Five Invitations and what they look like in practice - 45:20
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Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:03] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to the Doctors Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build health care institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions. We meet with deep thinkers, working across health care, from doctors and nurses to patients and health care executives. Those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Henry Bair: [00:01:03] "Death is not waiting for us at the end of a long road. Death is always with us in the marrow of every passing moment. She's the secret teacher hiding in plain sight, helping us to discover what matters most." So writes Frank Ostaseski, a respected Buddhist teacher and pioneer in end-of-life care. Frank is the founder of the Zen Hospice Project in San Francisco, the first Buddhist hospice in America. Over the course of his career, Frank has accompanied over 1000 people through the dying process. These experiences have taught him lessons on how maintaining an ever-present consciousness of death can bring us closer to our truest selves. He describes these lessons in his bestselling 2017 book, The Five Invitations. In this episode, Frank joins us to share his unique life journey and his hard-earned wisdom. Over the course of our deeply reflective and even meditative conversation, we discuss matters ranging from Japanese death poems to Buddhist mindfulness practices to what courage looks like in the face of death. Frank, welcome to the show and thanks for being here.
Frank Ostaseski: [00:02:12] Happy to be with you. I hope we can be of some small service to the listeners.
Henry Bair: [00:02:16] Unlike many of our guests, you are not a clinician by training, but you have been at the forefront of leading a change in the way that we think about end-of-life care. And you have personally accompanied many patients who are nearing death. That's a really fascinating career to find yourself in, and we would love it if you could set the stage for our audience and tell us what first drew you to this career, this this work.
Frank Ostaseski: [00:02:46] Well, that's always a tricky question, right? Because what gets us started and any one thing, you know, I think a lot of us who are working in health care had a calling way back when we were very young, actually. But to keep the story shorter, I'll just say that San Francisco was kind of ground zero for the AIDS epidemic. And I would say I cut my teeth on the AIDS epidemic. Prior to that, I worked in refugee camps in southern Mexico and Central America, where I saw a lot of horrible dying. And when I came back, I was I wanted to put what I had learned in those places to work. And just then, the AIDS epidemic was beginning. So we jumped in and so tried to do the best we could. The Zen Hospice, which was the first organization I started, was a kind of fusion of spiritual insight and very practical social action. We work mostly with people living on the streets of San Francisco who had little or no financial or family support. And so we became their home and their family and collaborated with the local hospice providers to get them the care that they needed.
Tyler Johnson: [00:03:52] And Frank, many of our listeners are either physicians or aspiring physicians, nurse practitioners, nurses, other health care practitioners. And so they have a sense when we have a physician on the show for sort of the day to day what that person does. Can you just talk a little bit through what is your day job like? What is it that you actually do?
Frank Ostaseski: [00:04:14] Well, my day job has changed. When I was at Zen Hospice for almost 20 years, I was the director of that program, and I also functioned as the primary counselor, if you will, to the patients that were served through our residence program and our volunteer through our in-home support programs as well. So I was both the support to our staff and volunteers, but also to the patients and their family.
Henry Bair: [00:04:40] And what did that support look like?
Frank Ostaseski: [00:04:46] On any given day, it could look quite different, actually. You know, over the years, I've developed a lot of tools. I've got a whole big yellow toolbox full of tools that I carry with me and have been beneficial. But I don't set that toolbox down between me and a patient if I do. One of us is sure to trip over it. So I don't lead with my tools. I lead with my humanity. And when I need a tool, it's there. I can pull it out of my back pocket and use it as best as needed. But I lead with my humanity. And what I've found over the years is that most of my work was human to human contact. We might even call it heart to heart or soul to soul contact with patients. And then often I was an interpreter for them between clinicians. And then that was off. That was often a big part of my job, being a middleman, if you will, an interpreter, agnostic, intermediary. These days I spend most of my time teaching around the world, teaching both clinicians and caregivers and people are simply interested in how do I what can I learn from death that might help us to live more fully?
Tyler Johnson: [00:05:57] So can I pick up on a thread that you've brought up right there, which I think is really important for our listeners, many of whom will grow up, so to speak, to be doctors or other health care practitioners. So you mentioned this idea of being face to face or heart to heart with the patient and then responding to whatever they needed in the way that they needed it. And then right thereafter, you mentioned that one of the roles you often found yourself playing was as the interpreter between a patient and their doctor or health care team. That's a striking thing to me because there's a part of me as a doctor that wants to say, What do you mean, an interpreter? I don't need an interpreter. I'm talking to the patient. Right? I don't really think that. But I can imagine that there are some doctors who might wonder, why is there a need for an interpreter? Or what precisely was it that you were interpreting? Or maybe if you have stories to illustrate that, I think that's actually a really powerful idea.
Frank Ostaseski: [00:06:55] You know, here's an example. I was working with a man, came off the streets, was living with us at our hospice residence. He had an ongoing relationship with his physician, an oncologist, radiation oncologist. He had an appointment that he'd set up months before for a radiation oncology appointment. And now he was in a hospice. And there was some question about what the value of that particular treatment plan. And so I said, you know, we can cancel this appointment if you like. And he said, No. He said, If you want people to help you, you've got to show up. It's that kind of guy. And so I said, okay, well, we'll go. And so we went to the big university hospital here and walked in, met with the radiation oncologist who began immediately kind of laying out a lot of clinical information for him. And I wasn't going to be the interpreter of that information, but I could be an intermediary. That helped the clinician to see that he was at a different stage in the last time she saw him. And that he was now weeks from his dying.
Frank Ostaseski: [00:08:00] It was it was very close to active dying. She wasn't accustomed to that. She was only accustomed to fulfilling her role and going forward with the procedure and the appointment asked was scheduled. And so in that case, I had to really the way I intervened was to say, Jackson, is this do you think this is really valuable for you now? Would this be how do you want this now? I didn't even value judgment. That was value. I just said, do you want this now? And he he said, Well, I don't know. And I said, Well, how do you think it'll help you? And we began to have those kinds of conversations about what he wanted at this stage of his life that wasn't about the efficacy of the treatment plan. But it was about what did he actually need at this point? And helping draw out his draw him out a little bit and let him express what those what those needs and what he wanted at the stage of his life. So that's a simple example, really simple example.
Tyler Johnson: [00:09:03] As a medical oncologist myself, I know that I have over the years become really grateful for people who are willing to kind of stop me in the stream of my thinking. Because it's just true that both by personal inclination and often because of the way that modern medicine functions, it's easy to get into a sort of stream of thought or a stream of action, right? Where in my case, it's often has to do with chemotherapy. And the thought is always sort of, okay, what's next? What's next? What's next in terms of which chemo drug is next? And sometimes the most valuable thing that that I as a practitioner can have is someone, whether it's another member of my team or a family member or the patient themselves, who stops and says, Now wait a minute, you're having a really interesting conversation about this versus that chemo. But what about is chemo really even the right thing anymore? Right. Asking that deeper question is sometimes one of the most helpful and necessary correctives that I receive wherever it comes from.
Frank Ostaseski: [00:10:11] Yeah. Tyler, you've laid it out very beautifully. So as a physician, you have to attend to both task and relationship, right? You know, a lot of us are very good at. We're very task focused and we're really good at that. But we also have to tend to relationship. Then, of course, there are those nurses or doctors who are all about relationship and sometimes the tasks don't get done very effectively. So oftentimes what I was doing was being a reminder of the importance of those two things, working side by side, task and relationship. And by the way, I worked on it. I worked with the physicians around that, not just as an advocate for the patient. I mean, here's an example. Women came to my workshop, a physician, young physician, probably like one of the residents that are listening to this call. And she said. You know, I'm going to be working with dying people in a big metropolitan hospital. Could you give me some Buddhist practice that I could do that would help keep me grounded? And I said, No. And she said, Why? And I said, Because you have your own lineage that you have to look to. You know, your really goes way back to the Greeks. Let's let's see if we can find something within your own lineage.
Frank Ostaseski: [00:11:20] I said, you know, when you put on that white coat, it could be like putting on a ceremonial robe. Now, that might have been a little bit of a stretch, but. And we began to talk about her lineage, which, of course, included a father who was a doctor and a grandfather who was a doctor. Not an uncommon experience for a lot of physicians. And I said, look to those. Look to those, look to that lineage. See what you can find. Anyway, several months later, my dear friend Rachel Naomi Rehman, who many of you know her work, came to me and said, "Do you know such and such a physician?" I said, "Yes, I think she was doing all right programs." And Rachel said, "What did you say to her?" And I said, "I don't recall. Why?" She said, "Well, she came to one of my support groups and you know what she's doing now?" I said, "no." And Rachel began to explain that this young physician got her grandfather's black bag, put it in her locker. Got her father's stethoscope, put it in her black bag and got some rose oil from her grandmother, who liked to work with herbs. In any case, when she had to go and pronounce a patient dead, she went down to her locker, got a black bag of grandfather's black bag, took out her father's stethoscope, Listen to signs.
Frank Ostaseski: [00:12:32] Made all the correct protocols and then anointed them very gently, kind of secretively with a little bit of rose oil from a grandmother. And this was the practice she did for years after that. And I think that she found something in her own tradition that was incredibly valuable to her and kept her balanced in her work, actually, kept her human in her work. Now, that's not everybody's answer, of course, but it was skillful for her. Very skillful for her. So I think speaking to the physicians and the residents that are on the listening in on this program, I think that's what they have to find. I mean, they're witnessing incredible suffering every day, unbelievable suffering. And this is not normal. I want to say to your residents, you are not normal. You know, very few people bear witness to this kind of suffering every day And going home and watching Netflix and having a glass of wine is great, but it's not going to be sufficient to help you integrate the suffering that you have borne witness to. You need something else.
Tyler Johnson: [00:13:34] That really resonates with me. I remember one time a number of years ago when I was an oncology fellow, when my wife and I went with two friends of ours, both of whom were in business, to go up in San Francisco to watch the play version of "The Mysterious Incident of the Dog in the Nighttime" or whatever, which is this very, very striking, but also sort of it's almost an assault on the senses. The point of the play is to try to sort of help you to feel what it would be like to go through a subway ride and all of these things as a person who is autistic or has other sort of sensory neurocognitive abnormalities. So it's a lot of bright lights and loud sounds and sort of high stakes drama and whatever. And all of this is to say that when we got out of the play, we were all sort of talking about how we had liked it. And the other three people thought, "Oh, it was so wonderful. And it delved into all of these morally complex questions and it was this and that and the other thing." And I was just like, "No, I have enough moral complexity in my job. I just want like Saturday morning cartoons or something." Like it was just because you're right that most people this is just not bearing witness to unending suffering is not what most people do in their day jobs. Right. And it puts you in a totally different frame of mind, even for how you encounter the rest of the world.
Frank Ostaseski: [00:14:56] Yeah. And so what what are the things that people, physicians would need to do or clinicians would need to do to allow that kind of integration to occur, to metabolize, if you will, their experience. You know, of course, at the beginning of a pandemic here, you all were working on the front lines, I'm sure. Yes, I am. I was working a lot of er docs, for example, in New York and Houston, places where the pandemic was wildly out of control. And this is what we talked about. How do we stay balanced? You know, when I was working in at Zen Hospice, you know, it wasn't uncommon for me to witness 30 or 40 deaths in a very short period of time, a week, two weeks sometimes. How did I stay balanced? So I went to my meditation cushion. I'm a Buddhist teacher, so I went to my cushion. But that simply wasn't enough. You know, it just wasn't enough. It stabilized my mind. It was helpful, but it wasn't enough. So I went to a body worker and I went once a week to a body worker. And, you know, I walk in the door and he'd say, Where? Today? Frank And I put my hand on my shoulder and I said, just there.
Frank Ostaseski: [00:16:02] And he said, okay. And I'd lie down the table and he'd make contact with that spot that I pointed to. He didn't do any woo woo California stuff, you know, You just put his hand on my shoulder, on my chest. And honestly, Tyler, I would cry for about an hour. We didn't talk about it. We didn't process anything. But there was something about the company that made that possible and something about the physical contact that helped make that possible. And so he'd say, I see you next week. I said, Yep, come back next week, did the same thing again. But those two things sitting in my meditation cushion, getting that body work, those were very helpful, but it wasn't sufficient. So I would go to San Francisco General and go to the maternity ward where I knew the nurses. And on that ward, there were lots of babies born to addicted mothers. Crack cocaine and and alcohol. And I would take that give me a baby to hold. And I'd sit in the rocking chair and I'd rock this baby for a period of time, and I'd soothe their their throat and belly. And I could feel that I was being ofuse.
Frank Ostaseski: [00:17:06] I was soothing these children who couldn't swallow, basically, because they were their systems were so, so confused, let's call it. And that service work, that being able to soothe pain and suffering that I wasn't always able to soothe, frankly, in the hospice was really important to me. And I would do that before I would go home to my own four children. That was a way that I learned to stabilize, include, integrate, and also find a kind of resilience that was necessary for me to continue a network. So that's how I did it. Everybody's got to find a way, their own way to do it. But I can guarantee you that while there's a lot of good shows on Netflix, that's not sufficient to metabolize, to integrate, to include the suffering that you've seen. And you can't. It's not. Sometimes it feels like we're in a war zone and we can only talk to our colleagues who understand something like we understand it. But once in a while, I think you got to step outside that circle and talk to other people who will give you a different perspective on it, who will help you to know it's not normal what you're going through. Yeah.
Tyler Johnson: [00:18:22] Yeah. You know, I I'm also very sensitive to the fact that I think there's another, well, there's a whole complicated host of issues that that are brought to bear on this. What I mean is there are so many forces that, in effect, if not in purpose, drive trainees and young and even older physicians not to really grapple with the suffering that they see. Right? And so that may look like being in a place where medical training almost by definition, is relentless in its demands on its trainees. Right. It's not enough to just do well in your clerkships. Then when you go home, you have to study for the shelf exam, and then when you finish studying for the shelf exam, you're supposed to be working on your research project or buffing up your resume for residency or whatever it is. And and there's also just this sense that, you know, real clinicians can just kind of fight through the screen and don't really have to process those things. All of which is just to say that in addition to the allure of Netflix and everything else, I think it's just so vital that we as as health care workers recognize that, just as you said, bearing witness to suffering and and being with accompanying our patients in those very difficult times is a it's a if you like, a spiritual work that also takes a toll and that we, too, are broken. It may be a beautiful type of brokenness, but we too are broken by that work and we too need to find ways to seek healing, which, as you mentioned, Netflix and Facebook and Twitter and TikTok don't count. Right. There has to be a deeper well from which to draw.
Frank Ostaseski: [00:20:19] Yeah, absolutely. I mean, you know, otherwise the isolation becomes dangerous. I mean, yesterday I had dinner last night with a friend who's a psychiatrist, and she's got lots of trainees shadowing her. And and one told her yesterday, in fact, that she feels bludgeoned. Now, part of that is because of the pandemic, because, you know, this language even that we use, they're being redeployed. They're being redeployed. You know how it was, and particularly in the beginning of the pandemic, where people were being sent to departments where they never worked before. And they had to do their best and that had to do with shortages of staff, resources, etc., of course. But the language that was being used was practically militaristic. And you know, that's hard then to have a heart to heart contact or a human to human contact, if that's the context from which you are working. Yeah. So. I think staying human. While providing health care is not an easy job. And that's that's that's almost hard to slip out of my mouth, you know, because. But it's true. Staying human is not easy. You know, I was in I haven't shared with the studio audience yet, but about two years ago I experienced a series of strokes, one quite significant stroke. I'm very fortunate. I've I've done very well in my recovery. But during one of the five strokes that I had, I went to an E.R. and there was a physician there. And I was really struck by his the way he interacted with me. You know, your ducks can be cowboys. We know this, right? And this guy was attentive and incredibly kind. And I turned to him and I said, How did you get so kind to be in a yard and still be in your doc, you know? Not that your doctor can't be kind, but.
Frank Ostaseski: [00:22:27] And he said, Oh, he said, I have a mentor. And he said, My mentor did a lot of palliative care work, and he helped us to understand what we could do when there was nothing to do. So this changed the way I practice medicine. And he helped us to figure out some protocols. It would be helpful in working with someone at the end of life should they come into the E.R.. And I turned to my wife and I said, He's talking about Scott. And my wife looked at him and said, You're taking care of your teachers teacher. In other words, Scott, the man who had been his mentor, was one of my students. And and the way in which he then cared for me was really different. And it wasn't because he was worried about getting in trouble. It was that he had such a respect for his teacher. You know how it was when you're in med school, there were some teachers. You just had a deep admiration for, deep respect for. And you thought, Oh, yeah, that's that's the kind of doc I want to be. Yeah. That was so for this young guy. And he was remarkable with me. There wasn't much he needed to do medically for me. But there was a lot he could do relationally with me. And he was very, very good at it. So I think that that our patients want a human face on their medical care and. That means that we need a certain level of mastery in order to do this work.
Frank Ostaseski: [00:23:57] If I'm sick or if I'm dying, I want mastery. I want somebody knows what the hell they're doing. Right. But mastery isn't going to be enough. I need somebody who can also be comfortable with me in a territory of meaning, who can help me discover the value and purpose of whatever it is I find myself going through. You know, what's the purpose of this suffering? How do I meet it? Etc.. That's meaning. And meaning is important. We've been reminded several times. And man search for meaning, how it isn't that suffering that makes people destroys people, its suffering without meaning, that destroys them. So mastery and meaning those are important. But you know, there's a juncture at which in the dying process anyway, meaning falls away and grandma doesn't want to talk about her old stories anymore. What she did on Coney Island or the music that she loved. And now that's because she's turning in a new direction. She's turning in a direction toward what I call mystery. It's the best word I can find for it. And it's the land of unanswerable questions. The place where we have to bear witness to the person discovering their own truth, even if it's one we don't agree with. So those three three M's, I call them mastery, meaning and mystery are all, all territories that if the physician or the clinician has to become comfortable with, has to become knowledgeable, it has to become skillful. And you don't get that in med school, but you get it from your mentors. You get it from people like you. Tyler Yeah.
Henry Bair: [00:25:39] I wholeheartedly agree. As someone who's currently in medical school and being inculcated in 100% Mastery and as someone who has also been fortunate enough to have Tyler as one of my mentors. Frank, Thank you.
Tyler Johnson: [00:25:54] That was very kind of both of you to say. Just parenthetically.
Henry Bair: [00:25:58] Frank, thank you so much for sharing these beautiful stories. I'd like to turn it in a subtly different direction. You have mentioned several times now that you are a Buddhist teacher, and the Zen Hospice Project is notable for being the first Buddhist-influenced hospice service.
Frank Ostaseski: [00:26:17] Institutions in the United States. Yes.
Henry Bair: [00:26:19] Yeah. And I think that's really fascinating. And I'm wondering if you could tell us your story, your journey in Buddhism and how you found this, this this connection or how you bring your Buddhist practices in your worldview into caring for the dying and accompanying with them in very difficult times?
Frank Ostaseski: [00:26:37] Yeah, thanks. It's a good question. I want to say, by the way, that I'm no longer at the Zen Hospice, and the Zen Hospice is no longer in existence that that program isn't serving patients anymore. There's still an educational effort that it's doing. But the Zen Hospice, as it was, has gone. I am not. I have no missionary zeal, so I don't think Buddhism is any more important than anything else. And I don't. Honestly, I don't think caring for the dying is any more important than anything else. No more important than taking care of our gardener or caring for our children. But for me, it made sense because what I learned in my Buddhist practice, first of all, it didn't ask me to believe anything. There was no dogma I had to believe. That was based on practice. It was based on my direct experience. And what was it that contributed to suffering and what was it that might relieve suffering? Those are the two primary ideas that drive Buddhist practice. The other central teachings which were are appropriate to think of or to include rather in our discussion is the first of impermanence that everything changes, everything comes and goes. And I think we learn to rely on that. You know, we're happy that that cold we have today will go away. But we're not so happy when that treasured vase that your mother gave you, that you've been protecting for years falls off the shelf and breaks.
Frank Ostaseski: [00:28:04] But it's inevitable that it will. Every life will come and go. Every relationship will come and go. So the question that arises is how do you want to care for your life now? Huh? See, I think when we come into contact with the precarious nature of this life, we also come into contact with its preciousness. And then we don't want to waste a minute. Then we don't want to spend our time spinning our wheels. We want to invest in our life. Live a life that has some degree of integrity and purpose and is responsible. So that's the Buddhist part.
Frank Ostaseski: [00:28:44] The influence on the Zen Hospice project was what would it be like if when you're dying, you have around you people who aren't so afraid? Imagine how that would change the dining experience. Just that simple thing. People aren't advising you or counseling you or telling you how to die because you know it's hard enough to die without us setting up a lot of agendas about how people should do it. The so called good death is one of those. So our volunteers and staff all had a Buddhist practice, had a mindfulness practice. We could say that's maybe better than Buddhism. So they were cultivating capacity to pay attention to what's happening as it was happening and to learn how to keep one's heart open and help. Yeah. And that's a really different group of people to surround a dying person with. Then those who are saying, Please don't die, or I've got one more protocol I could try.
Frank Ostaseski: [00:29:47] Just that just the simplicity of that is in itself useful. So. I'm not I don't think we ever pushed any dogma on anybody. And very few patients ever asked me to teach them meditation. However. I remember one man coming to me and saying he'd come out of an acute care hospital setting and he said, I feel like when I came into this place, I've come into a sanctuary. He said, Here I can die. The kind of death I need to die. And I want to thank you for that. Yeah. There was a woman in our hospice. She lived on the margins of society, let's say. And one day she and I were sitting in the kitchen and I was reading a book of Japanese death poems. It's a tradition in Japan, not just for Buddhist monks, but for the public to write a poem on the day of your death or close to it that tells the essential truth of your life. Now, how awake do you have to be for that, right? So I said, What's that? And I said, I told her what I told her. The the tradition. And I read to her a few poems and she said, I want to write one of those. I said, Great, you should write one. What's the form? I said, Oh, there is no form. You just write it the way you write it.
Frank Ostaseski: [00:31:06] So she went upstairs to a room. A little while later, she summoned me. I mean, she summoned me and she didn't say could. Frank, could you please come? She said, Get Frank up here. And I came into the room and she said, Frank, I've written my death poem, and when I die, I want you to pin it to my bedclothes and I want to be cremated with it. And her name was Sono. And I said, Sono, I'd be honored to do that. I really thank you very much. I'll make sure that happens. And she said, But first, I want you to learn it by heart. I want to know that this poem lives in someone else's bones, she said. She didn't say, Memorize it. She said, I want you to learn it by heart. That's a different instruction. So I said, okay, teach it to me. And I stayed in the room with her and I learned the poem with her. And she wouldn't let me leave the room until she was sure that I knew the poem by heart. And when she died, I followed her instructions. It was pinned to her, her clothes, and I kept the poem. Here it is. This is her poem. This is a woman who lived on the margins of society, died with us in Zen Hospice and felt a certain kind of comfort in being in our company. She wrote:.
Frank Ostaseski: [00:32:23] Don't just stand there with your hair turning gray. Soon enough, the seas will sink your little island. So while there is still the illusion of time set out for some other shore. No sense packing a bag. You won't be able to lift it into your boat. So give away all of your collections. Take only new seeds and an old stick. Send out some prayers on the wind before you sail. Don't be afraid. Someone knows you're coming. An extra fish has been salted.
Frank Ostaseski: [00:33:02] This was her poem. But we never taught her a thing about meditation. She didn't care beans about Buddhism. But this was the influence of being surrounded by people who weren't so afraid of the dying process. And it's a beautiful poem. No sense packing a bag. You won't be able to lift it into your boat. That's a great line, right? Give away all your collections. What are you going to take with you to heaven? All right. She said. Take only new seeds and an old stick. I love that image. I think of farmers or gardeners. You know, they used to put a stick in the ground, in the dirt to make a hole and then drop a seed in it and then kick some dirt over it to cover it up. That's how farmers did it, you know. It's a beautiful image for her. And she said, and according to her belief, don't be afraid. Someone knows you're coming. An extra fish has been salted and. Beautiful.
Tyler Johnson: [00:33:56] Well, and the one thing that I want to put out there as a clinician who's a few years into the road, down the road of practice, is that while I totally hear what you're saying, Frank and I take you at your word that you're not trying to evangelize yet, it's also true that I as as a listener on the podcast, listening to you and trying to gather from you what truth I can. And in particular, I think that this truth is important because within the culture of medicine, the deep truth that you're teaching and the deep truth that her poem is teaching is countercultural. It is medically countercultural.
Frank Ostaseski: [00:34:36] Yes.
Tyler Johnson: [00:34:37] Because the reigning paradigm of modern medicine is what scientists would call the maintenance of homeostasis. Right? Everything is about how can we get the diseased organ back to not being diseased, Right. It's a it's to push against time and to push against change. It is in some ways the whole project of modern medicine is the is the maintenance of the illusion of permanence until you finally just can't even do that anymore. Right. And there are many times in cardiology and oncology and nephrology clinics, not to mention in the ICU, where where we spend enormous amounts of money and enormous amounts of emotional capital trying to maintain that illusion that impermanence is not real and that we are we've endowed ourselves with the ability to make ourselves permanent. And which is just to say that if you if trainees and young physicians can carry with them a an acceptance of impermanence, which doesn't mean, as you pointed out earlier, that you don't bring the mastery of your own discipline to do everything that you can for your patient. But at some point the leaven in the loaf has to be the understanding that in spite of all of our best chemo and surgery and radiation and ventilators and pressers and dialysis and all the rest of it, all of us will return to dust.
Frank Ostaseski: [00:36:13] Yeah. I mean, I thank you for mentioning all that, Tyler, because I think it's really important that we speak to the culture in which people are are being trained. And, you know, honestly, I also had a cardiac event. And so I'm really glad that my physicians knew how to take care of my organs. You know, I love that they have mastery. I love the brightness that happens in medical training. It's brilliant. It's really brilliant. However, dying is not solely a medical event. And I think we need to stop treating it as if it were, because I think it leaves a lot of people in a great deal of despair and fear because they're not able to beat the fight that they're in. You know, we're fighting against that cancer, whatever it is. Now, I'm not suggesting that everyone should sell a roll over here at all. But there's a juncture in which in this process, which dying is going to happen. And the question arises, how are we going to meet it, you know? You know, the African American writer, James Baldwin, the brilliant writer, Right. He said something like, Not everything that can be faced can be changed. But nothing can be changed until it's faced. And so I think one of the things one of the great lessons that we are talking about here is how do we as a culture, as a medical culture, is just a reflection of what's happening in the culture at large. So let's not blame it on doctors. I have a lot of empathy for doctors. But, you know, as a culture at large, how do we begin to include this in our life? And how might it support us if we include dying in our life? What might we learn? You know? Imagine if we stop compartmentalizing death from life. And and we began to think of it as something that had some something useful to teach us. Then might we go to it like a master teacher and say, please tell me, what can I learn? How can you help me lead my life?
Tyler Johnson: [00:38:20] So I want to jump in there. And I know I know this is something, of course, that you've you've written and lectured and taught and and lived extensively about. But, you know, I think that even as apart from most medical practitioners, you are rare in the frequency with which you have accompanied dying patients as in actually been in the room when they take their last breath. Yes. And I know that one of what I was mentioning earlier is that one of the main themes of your discourse then over the years has been what have those frequent encounters with death taught you? What is the message that you bring back to us? The living. And I think we'd love if you could talk about that a little bit.
Frank Ostaseski: [00:39:07] Well, I'm primarily a storyteller, so I find that people learn best through stories. There was a woman in our hospice. She was a 86 year old Russian Jewish lady, tough as nails.
Tyler Johnson: [00:39:20] Hair like barbed wire as in one, one old play.
Frank Ostaseski: [00:39:24] And just the kind of gal I like to work with, actually. Excuse me if that sounded misogynistic, but I really loved her. And so when someone was actively dying, and if I wasn't at the hospice, they would call me and I would go in for almost all the deaths. And I came into the room and Adele was her name. She was sitting on the edge of the bed in her nightclothes, sort of legs slightly off the floor, dangling off the edge of the bed. And sitting next to her was a very wonderful home health aide, nurse's assistant. So when I walk in the room, I saw this and I sit in the corner. I go and sit down on the couch in the corner. I don't walk in right away and jump in. I look and see is anything needed? Do I really need to help here? And let me find out what's going on before I leap in to save the day. So sitting there, I watched and I saw that Adele had was struggling with every breath. And this was despite the appropriate interventions of morphine and oxygen and other things and that. But every exhale and inhale was a struggle. And sitting next to her, this very wonderful home health aide, a very kindly, well-meaning way, turned to Adele and said. Adele, you don't have to be scared. But right here with you. And Adele was this tough cookie turned back there and she said, Honey, if this was happening to you, you would be scared.
Frank Ostaseski: [00:41:01] So I stayed in the corner, you know. And a little while later, I continued to watch. And this very well-meaning home health aide said, Adele, you look a little cold. Would you like a shawl around your shoulders or a blanket? Know. And Adele shot back. Of course I'm cold. I'm almost dead. Now, I hope I have half the tenacity of this woman when I'm dying. And I noted for a few months so I could be very honest with her. And I was watching this breathing stuff, you know, And so I pulled my chair very close to her, looked straight in the eyes, and I said, Adele, would you like to struggle a little less? But she said yes. And I said, okay. I said, I noticed there at the end of your exhale, there was this little gap before the next inhale. Now, some of you know, this woman is actively dying. She doesn't care beans about meditation. And I said, you know, I wonder if you could put your attention there just for a moment. I'll do it with you. I didn't teach her. I didn't guide her through some woo California meditation, just just breathing with her. She would breathe in. I would breathe in and she would breathe out. I breathe out just like that. And after a while I saw this kind of calmness come over Del's face and the fear which had been characterizing it seemed to relax. And I think Adelle found this place of rest right in the middle of things.
Frank Ostaseski: [00:42:29] You know, nothing had changed. None of the conditions had changed. She just found a place. That gap between the exhale and the inhale. You know that little gap there. She found a way of resting in that gap. Now this. This would work for everybody. But it worked for her. And then she said, Frank, it was okay with you. I'm just going to lie down. I own the pill and rest. I'm really tired now. I said, okay, great. She lied back on her pillow and not long after she died, very peacefully. Very peacefully. Now. This is an interesting thing to me. You probably know this, Tyler. I, I worked with a lot of people who had newly diagnosed with cancer. And what I found with them is they would often talk about what they called a secret gratitude. And I didn't understand it. They sometimes don't talk to their doctors about it, but they talked to me about it. And what they were saying is that once the initial shock of their diagnosis had passed. When that subsided a bit, they began to realize that they could say no to things, no to a party they didn't want to go to. No more work, no to certain kinds of conversations that they didn't want to have anymore. And so they found this kind of place of rest in the middle of things, you know, that's what I call it. They weren't obliged to say yes to everything anymore.
Frank Ostaseski: [00:43:56] So here's the question for me. Do we need to die before we can rest in peace? Her. Well, can we find that now? And I'm not just talking about the patients. I'm talking about those of us who are working with the patients, those of us who are clinicians. Let's not wait until we're dying to rest in peace or to learn the lessons the dying has to teach. So that's one of the clear lessons that being with dying has taught me. Don't wait. You know, waiting is full of expectation, waiting for the next moment to arrive. So we missed this one. I can't tell you how many times I've been with families who have said to us, When is mom going to die? You know, they're looking at the monitor, watching the cardiac wave. And waiting for the moment of dying. They miss everything in between. So don't wait is become a kind of what? It's one of my five invitations, but it's also a guiding principle for me in my life. If there's someone you love, don't wait to tell them you love them. Yeah. Tell them now. It's a it's absurd gamble to imagine that a time of our dying. We will have the physical strength, the emotional stability, the mental clarity to do the work of a lifetime. This is an absurd gamble, and I don't recommend taking that bet now. So I think it is practice now. Do the work now.
Henry Bair: [00:45:20] So, Frank, you've just mentioned your Five Invitations, which we haven't actually discussed yet. Of course, that is the name of your book from a few years ago, and we will be sure to put a link to the book as well as related online resources in the show notes to this episode. Can you share with us what the five invitations are and perhaps share some stories that illustrate them?
Frank Ostaseski: [00:45:45] I'm happy to. Basically, the five invitations are mutually supportive principals, reliable guides, we could say, to being with dying. But it turns out they also have a relevance for the rest of us and living a life of of meaning and purpose, one that's characterized by some compassion and wisdom, I hope. So the five are The first is don't wait, don't wait. I just spoke about that. You know, the second is welcome everything. Push away. Nothing. Now, that sounds like a make a great bumper sticker, but how do you do that? Is it even intelligent? A welcome everything, push away nothing. And I think what this one is saying is not that we have we have to like everything that comes. It just means we have to be willing to meet it if it's on our doorstep. Can we meet it? One example of this was a man that I knew who was a well renowned psychiatrist, and he developed Alzheimer's in later years. And so he was often quite confused. And friends of mine went to his house for dinner, rang the doorbell. He opened the door with a kind of blank look. And he said, I'm sorry, I don't recognize faces anymore, but I know this is my home. My home has always been a place where people welcome. So I know if you're standing on my doorstep, my job is to invite you in. Now. Wow. What kind of a life do you have to have that allows you to make that kind of statement at that stage of your life? Yeah.
Frank Ostaseski: [00:47:14] So the welcome everything, push away nothing. That's a wow. That's a way of us- It's asking for a certain kind of fearless receptivity to life, I would say. Yeah, that's what it's really inviting, I think. Yeah. The next one is bring your whole self to the experience. Bring your whole self to the experience. So that means, you know, when I'm working with someone who's dying, well, someone who's grieving a loss, I'm looking at my own fear, my own grief as well. I'm not trying to put it beside. I'm actually including it because it's what allows me to build an empathetic bridge to the other person's experience. If I haven't done my homework and I say I understand, well, that patient's going to yell bullshit and they're going to know I'm not a reliable, trustworthy resource for them, a trustworthy companion. So to bring your whole self to the experience means to bring everything. That means to bring your expertise, but also your weakness, to bring your skill sets, but also your your fear. Because all of those are meeting places with the person that you're serving. So I think that that's important to include. The next one is find a place of rest in the middle of things. I alluded to this when I spoke about Adele. You know that, you know, we're always thinking we're going to find rest when we go on vacation or when a shift is over or when we're you know, if you're a meditator, you're going to meditation, retreat are some such thing.
Frank Ostaseski: [00:48:50] I think we have to learn to find rest right in the middle of what we're doing. Because when you're running, you know, 72 hour shifts or you're caring for a loved one at home, you can't step away to rest. You've got to find a way of resting right in the middle of it. And I think we do that, Henry, by bringing our attention fully and completely to whatever it is we're doing instead of being split and distracted. You know, think about what it's like when you're giving yourself to reading a book, you know, or watching a film and giving your attention fully and complete to that experience is actually quite restful. You know, when my daughter was in junior high, she went to a Catholic junior high, and they asked me if I would come in and teach something about Buddhism. You know, these were tweens. And I said, okay, today we're going to learn about kissing. And the teacher in the back of the room was like, What? And I said, No, we're going to learn about kissing. I said, This is how it is. I said, When you're kissing someone, you want to be there for the whole experience. You don't want to be looking at your watch or out the window. You want to be focused on the person that you're kissing and you want to feel the entire experience of it, every sensation. I said to them, You know, the lips have a million neural receptors.
Frank Ostaseski: [00:50:11] It's 100 or 100 times more receptive or more sensitive than your fingertips, you know. And so I said, This is what's important about kissing. Being there for the experience. And it's true in caring for people who are sick or dying. That's important to bringing your whole self to the experience. So let's see, I've named them all that little bit out of order. But the the last one is Cultivate Don't-know Mind, Don't-know mind. I know that I felt obliged to put something Zen like in the list. And Cultivate Don't-know Mind. What does that even mean? I mean, is that an encouragement toward ignorance? I don't think so. I think a Don't-know Mind is a mind that's characterized by curiosity and wonder and deep interest. It wants to know. It wants to know. But when we're so filled up with our knowing, we have no there's no room for anything else to enter. We only see what our knowing allows us to see. And so Don't-know Mind is a mind that's relaxed, receptive. So I think you can get the idea that a Don't-know Mind is a mind that's fresh. It looks with fresh eyes. You know, it sees situations in a new way. Each time it encounters. It doesn't mean you throw out your experience and your skills and your past learning. But you meet this time, this moment, fresh. And I think that's a really important quality to not only be with and being with dying, but to bring to our everyday life.
Tyler Johnson: [00:51:45] I think that the thing that strikes me unavoidably about those lessons and in a sense, the golden thread that ties them all together is the reminder, You talked earlier about the fact that we can't approach death as a purely medical experience, but I think it is also true that we can't approach life or the preservation or prolongation of life as a purely medical experience. I think what those truths and your entire way of engaging with these subjects and with life, what they suggest to me is they remind me that there is an unavoidably spiritual aspect to living and to dying and crucially, to caring for one another.
Frank Ostaseski: [00:52:36] Absolutely. Tyler. And, you know, let me just make it clear I am not romantic about dying. It is the hardest work you will ever do. I am not interested in rainbows and crystals. That's not the way in which I am. I'm with, you know, I work with tough people who live on the streets. I mean, they have no spiritual practice. They have no family structure, you know? And yet I have seen them regularly in the process of dying in the final months, the final days, the final moments of life sometimes come into contact with something that has them emerging as something larger than the small, separate self they've taken themselves to be. Now, understandably, we might say too late. And I agree. I think it's too late to wait until then to do that kind of exploration. But here's the thing. If that kind of transformation is possible, then well, it's possible now. And I think what dying does when we're willing to go toward it is to help us understand what matters most. And that's what guides that's what guides our everyday life. That's what helps us to live with some degree of wisdom and compassion.
Tyler Johnson: [00:53:47] And I think I will say that every once in a great while I will witness a physician or a nurse or other health care worker, like maybe the one that you mentioned from the emergency department who lives as if they had already died and who seems to carry with them this inner sense of what really matters because of some deeper transformation that was cultivated in whatever way that that happened for them. And those people have a transformative effect in my experience on everyone they encounter.
Frank Ostaseski: [00:54:26] I agree. And, you know, and I don't have a formula for this. I don't have a formula how someone's going to make that sort of discovery that you're speaking of. Anybody who says they do is, I think, not telling the truth.
Tyler Johnson: [00:54:39] We were hoping for Frank's three step program for Transformation Epiphany.
Frank Ostaseski: [00:54:43] I have a Powerpoint. I have a PowerPoint presentation for that. But that's going to cost you a lot more, you know?
Henry Bair: [00:54:49] Well, Frank, we want to thank you again for taking the time to join us and share your incredible insights and importantly, all of your wonderful stories.
Tyler Johnson: [00:54:58] Thanks so much, Frank.
Frank Ostaseski: [00:55:00] Nice to be with you, Henry. Nice to be with you, Tyler. I hope there's been this is of some small support to our listeners.
Henry Bair: [00:55:07] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program, notes and transcripts of all episodes at the Doctors Art. If you enjoyed the episode, please subscribe, rate and review our show available for free on Spotify, Apple Podcasts, or wherever you get your podcasts.
Tyler Johnson: [00:55:26] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient or anyone working in health care who would love to explore meaning in medicine with us on the show. Feel free to leave a suggestion in the comments.
Henry Bair: [00:55:40] I'm Henry Bair.
Tyler Johnson: [00:55:41] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.
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LINKS
Frank Ostaseski is the author of The Five Invitations: Discovering What Death Can Teach Us About Living Fully.
