It's good to be with you today. Mostly now I'm a facilitator, but it's good to do some practical thinking as well. I do have conflicts, which is that I may or may not make $0.75 if you go buy one of my books on this topic. But I don't think the deans and dons of Oxford really give two shakes of a rat's tail what I tell you today. These are just the CME objectives, whatever CME means, speaking of vacuous rituals. But what I actually want to talk to you a little bit about today is some of the words that we use, what religion and ritual might be or mean, particularly as they apply to an ICU setting, think a little bit about death, and then some review of the evidence such as it is and the practicalities involved. The word religion, which we use sometimes in really vexed and confusing ways, is a Latin word used in ancient Rome. In ancient Rome, it actually referred to the responsibilities of regular people to honor the gods. And there were gods of the state, and there were gods of the city, and there were gods of the actual house. Each house had its own god. The gods called manes, not mayonnaise, but manes. And there were debates even back then, 2,500 years ago, 2,000 years ago, about what religio meant. And the two leading contenders were that religio means to bind intensively, like a ligation lig, to tie together. And the other competitor was that it comes from the same root as lair, to read, so reading carefully. The re is an intensifier. The reality is nobody actually knows what the truth is. No one knows where that word originally came from. And J.Z. Smith, a famous professor at University of Chicago, now of blessed memory, wrote a highly influential and very interesting paper some years ago called Religion, Religion's Religious. And in it, he really defined the nuances and complexities of defining the word religion. And if you were to try to summarize in just a few words his arguments, it's that religion is a lot of things wrapped up together. It's attitudes. It is beliefs. We talk a lot about beliefs, but it's not just beliefs. It's also practices, and it's also cultural expectations. What surprises you or doesn't surprise you when you interact with other people? That's what cultural expectations are. And that cluster of things orient and relate us to something that's greater than we are in some ultimate way. So filling out your tax forms relates you to something greater than you are. The IRS is clearly greater. There's nothing particularly ultimate about the IRS. So religion is about this constellation of things that orient us to something greater and that feels ultimate, more important than the merely physical. Now ritual, the way we have tended to use ritual is actually as a synonym for religion as it was understood back in ancient Rome. But classically, people have felt that it's some sort of a physical act and speaking is itself a kind of physical act. And it is metaphysical in scope. It points, again, beyond itself in some important way. And the contribution of Catherine Bell, this book, also quite dense and also quite interesting, really set and established a whole new discipline of ritual studies. And in it, she makes the argument that fundamentally, ritual is social. If you do something utterly idiosyncratic, even if it's physical and points beyond its physicality, that's not ritual. That's, you know, it could be a lot of different things, but it's not ritual. But stuff that's done together in some important way likely is a ritual. And there are plenty of rituals. In that middle bullet point there, I talk about the fact that a lot of things we do and casually don't even notice are rituals. But I think ultimately, most of us would agree, and certainly the people for whom rituals are self consciously a key part of their lives, feel like it's more than just a credit card receipt. There's something about that activity that points, again, toward ultimacy. This Peter Berger, now deceased, Boston University sociologist. And this is one of the more famous lines of religious sociology. I'll read it for you. It's actually quite controversial, but I think it's important to consider. The power of religion depends, in the last resort, upon the credibility of the banners it puts in the hands of women and men as they stand before death, or more accurately, as they walk inevitably toward it. This was an influential set of beliefs, some of it driven by Freud, now of not so blessed memory in recent years. And people are understanding that religion is about a lot more than just making sense of your dying. Nevertheless, it's true that as you grapple with death, and as you grapple with your own, or the death of a beloved, boy, you wonder about ultimacy. Boy, you do. Now, what about death? I've been thinking about death for a long time. We all, working in the ICU, think a lot about death. But it's actually impossible to define in prospect. In rapid retrospect, yes. Five minutes later, sure. But at the moment, you don't know. You don't know whether that breath was the last breath, whether that systole was the last systole. A lot of arguments about it. They were pretty intense in the 60s and 70s. They continue intense. And I would say pretty close to a consensus definition is that there is a failure of homeostasis. It has to be irreversible. So an ischemic leg is a failure of homeostasis. If it doesn't infarct, if you get to the thrombectomy quickly enough, it's not irreversible. So that's OK. So it has to be irreversible. And there has to be a failure of homeostasis. And it has to be widespread. A dead foot, you amputate. The person is not dead, but the foot is. And ultimately, what's intended is that the widespread extent of it is such that the integrated organism no longer functions or exists. Now, the life support technologies that we employ routinely in the operating room as well can complicate this definition. A person who's deeply anesthetized during surgery would, in the absence of life support technologies, in fact, be dead, just as is the case of a person who meets neurological criteria for brain death and who has multiple organ dysfunctions. It's very complicated. But lest we get too wrapped up in here, I think of Dr. Hirshberg's important reminder that we are not the key players in the room when we're thinking about death. Whatever we think of the physiology, it is a shattering event. It is a fundamental change in the person who is dying and the people who love them. But what about us? We are who we are. We are clinicians and researchers in the intensive care unit. What is it that bothers us or wonders us about death? I think there's the fact of death, the timing of death, and the way of death. The fact of death should bother us. If a patient ought to have survived and through our oversights or negligence does not survive, that ought to haunt us, haunt us enough to do better, not haunt us enough to quit. But there is that moment when we confront a death of wondering, are we and our systems providing the care we ought to be providing? Have we been adequate? Timing is hard. Dr. Hirshberg alluded to that, and it's something we all live with constantly. When has a person's time to come? What is the projected probability of survival under treatment that is sufficient to motivate carrying on? When do we make sense of the wrapping of a life? And Dr. Jackson mentioned those differences in timing. Dr. Hirshberg talked about the role of agency in dying and how brutal and unwelcome the decision to wish the death of a beloved can be in an intensive care unit. But that's part of what worries us. And then there's the way of death, which I think we can all do a little bit better about. How do we aid the process of bereavement in those influential first hours and days? How do we avoid abandonment? How do we not disengage when we put someone on comfort care and go off to the next patient in wild physiologic disarray? How do we help to manage the humanness of that way of death? There are a lot of different ways to honor and celebrate an individual dying that come from traditional religious ritual. This is a list of some of those. My own religious tradition uses anointing with olive oil and blessings that involve touching of the head with the hands. For Catholics, the sacrament of the sick replaced some decades ago the, I've even forgotten the old, I've even forgotten the old, the last rites they used to call it. This is now the sacrament of the sick. It's a kind of ministering to the person. I had the great honor as a young Ute man died in our ICU of being asked to participate in a ritual that involved dried sage and an eagle feather. Buddhism and in Judaism and in a variety of other traditions there are prayers or chants or songs that may be sung. And it's common as someone wraps up to reflect on the meaning of a life, how well it has been lived, and to think about what matters most. And that's what these confessions of sometimes of failings and of trying to make right or reconcile and confessions of belief and faith might have a role. There are some data. I'm a scientist, I like data. They're not necessarily the kind of data that we want, but there are data. Judy Davidson's group in Southern California has worked on sense making. How do you help people make sense of something like a death and that's by being actively involved in the care of the patient, perhaps by moisturizing hands and feet or helping with respiratory therapy tasks. Deb Cook in Chicago, sorry, in Canada, different C word, developed the Three Wishes program with her group. And that was basically saying, what can we do as a social group to honor the individual who's dying by honoring three special wishes? And I think most of us have done informally something like that, smuggled a dog or a cat into the ICU, grabbed a bottle of wine, got a recording of some beautiful song that means a lot to them. So this was an attempt to formalize what a lot of us have done informally. And then Randy Curtis, who himself is grappling with mortality as the present time as we know, and honor him, has done a lot of really careful work around communication interventions. And what do we do with the data? So far, the data mostly suggests that people like the idea of these interventions, but they have not in general tended to modify the course of bereavement or to have improved the psychological health of the people who survive the death of a loved one. And there's some cautionary tales. I honor Randy for doing the hard work of running RCTs and of having to acknowledge that occasionally the RCTs suggest that people are worse off after the interventions. One influential and important paper from Randy's group showed that if you empowered and trained the house staff to have end of life conversations, it made the family members more depressed and more anxious. It's a cautionary tale. Elie Azoulay's group in Paris looked at condolence letters, which I routinely wrote before that paper. And it turned out that it made things worse to have sent routine condolence letters. If there's a special connection, I'll still send a note, but I won't do them routinely anymore because the RCTs suggested that sometimes the interventions backfire. So my take is at the bottom there. You gotta be humble. You gotta let the arrogance go away. Sometimes you need the arrogance to solve acute physiologic muddles fine, but for this, no. And remember that the data don't necessarily always tell us everything we wanna know. And that for a lot of us, rituals and human connection are not actually attempts to put a quarter in a vending machine and get a Diet Coke out. They're more than merely utilitarian. So these are some of my rules. I think it's appropriate to encourage consideration, not to proselytize either the absence of religion or the presence of it or any particular option within that, but just to wonder together, is there something about the ultimate that would matter? And I give you here some example language. As long as you're asking with true curiosity, are there any special ways that you and your community might mark or honor a death? And would you like us to try to facilitate that? Gentle, but open. Because if we refuse to talk about it, we're suggesting that we stigmatize something that may be the most important part of their lives. And then it's fine, we don't, we're intensivists, so we think we have to be the specialist in everything and somehow we're less noble if we have to phone a friend. But there are specialists who are good at this and it's okay to phone a friend. We're not gonna replace a mitral valve on our own and we don't have to go it alone, particularly when it has to do with these special rituals. And then a colleague of mine who identifies as non-religious asked me to throw in this slide because this is something that'll come up. What do you do if you're not religious? Like not, you think of yourself as an absolute atheist, but then people come to you and they ask you a religious question. And one of the really important religious questions people ask when something terrible is happening is why? Why would God let this happen? And I'll be honest, I'm personally quite religious. I'm a practicing Latter-day Saint. And I can tell you from these trenches, most of us have some guesses, we have some hunches, but we don't know for sure. Instead of knowing concretely the specifics, we have confidence that there is meaning rather than non-meaning, that there's more than just the dance of atoms. And we have confidence in the possibility of relationships that are more than merely material. That's what we've got as we operate as religious people in the face of something very difficult. And I phrased it that way because I think most of us, whether we think of ourselves as religious or not, have some intuitions about that. Some intuitions about what a meaningful life might look like, what fullness might be, what the ultimate might be, even if we don't identify it with God or with a particular religious community. And my best guess is that this is a moment to allow some introspection and for us to wonder too why exactly is life the way it is and then to listen gently. And to understand that commonly when people are asking this question, they're not asking a theological question. They're really wondering what good or meaning or healing can come from this terrible thing. And that, I think, whether you think of yourself as religious or not is something you can wonder about with them. And I give sample language. I wish I knew. Tell me what you think. But that's that kind of introspection and gentle listening. This is heavy stuff and I will leave you. Some people die. They do. That's my wife of blessed memory. Thank you.

religion

ritual

death

ICU setting

bereavement