Restoring Dignity at the End of Life

Sunita Puri: I had to learn that I as a person and as a doctor had no control over how somebody is going to hear and receive and process information. My role was to do it compassionately and honestly, because honesty is the compassion. And then to be with them as they process what they’re going through. It was also learning to be honest, to sit with my own discomfort about the things I couldn’t fix because when you can’t fix something in medicine, you feel like a failure. At least I did. And now you’re sitting with people whose cancer you can’t cure. You’re sitting with people whose anguish you cannot take away. So how do you unlearn your own discomfort? How do you learn to be with uncertainty? Because you have to help your patients be with uncertainty. And that also is not something that we’re taught.

James Shaheen: Hello, I’m James Shaheen, and this is Life As It Is. I’m here with my co-host Sharon Salzberg, and you just heard Sunita Puri. Sunita is a writer, a palliative medicine physician, and an associate professor at the UMass Chan Medical School. In her memoir, That Good Night: Life and Medicine in the Eleventh Hour, she explores her journey to help patients and families redefine what it means to live and die well in the face of serious illness. She also recently wrote an article for Tricycle on navigating love and loss through the lens of impermanence. In our conversation with Sunita, we talk about the importance of unlearning our assumptions around death. how language can shape people’s experience of illness, how she has learned to regard death with reverence instead of fear, and how working with dying patients influences how she lives her daily life. So here’s our conversation with Sunita Puri.

James Shaheen: So I’m here with Dr. Sunita Puri and my co-host Sharon Salzberg. Hi, Sunita. Hi, Sharon. It’s great to be with you both. 

Sunita Puri: Thank you for having me. I’m excited to be here.

Sharon Salzberg: Hi, good morning.

James Shaheen: So, Sunita, you work as the program director of the Hospice and Palliative Medicine Fellowship at the UMass Chan School of Medicine, and you recently published a memoir, That Good Night: Life and Medicine in the Eleventh Hour. So for our listeners who may not be familiar with palliative care, can you tell us a little bit about the field? How do you define palliative care? 

Sunita Puri: Yes, certainly. So the term palliative care is a really confusing one, I think, for a lot of people. The very basic way I summarize what we do is that we focus on relieving suffering—and suffering that’s often in the background when high-tech medicine is really focused on curing and fixing. So when somebody gets very sick, they can experience physical suffering, for example, pain from cancer or shortness of breath from heart failure, and we treat that with medications and other interventions. But we also attend to the emotional, spiritual, and existential suffering that people experience when they become sick and how that type of suffering changes as their disease progresses.

So, for example, people often grapple with their relationship with God when they get sick. Does it break their faith? Does it strengthen their faith? They wonder existentially, What will my life mean now that I’m sick and I can’t be the partner I was or I can’t go to work as I was? Who am I now? And all of those domains of suffering are the things we really focus on in palliative care.

James Shaheen: So how did you come to palliative care?

Sunita Puri: So, I think there’s two parts to it. One, I really wanted to follow in my mom’s footsteps, and she’s an anesthesiologist and did critical care and worked in the operating rooms. I used to round with her when I was five years old, and she would take me into the Post-Anesthesia Care Unit and see patients with me. And when I got to residency, I felt pretty lost because the things that I was most compelled by were the questions of not can we do something, but should we do something for the specific person in front of us? So for example, if someone came in with a bad case of the flu, a ventilator might make sense to help bridge them through that, but does the same technology of ventilator make sense when somebody is dying from end-stage cancer? So these were the questions that really started to compel me and made me really interested in how we apply medicine to the goals and the values of the human being in front of us, not just the pair of lungs or the heart. And so although I did a lot of ICU rotations, the thing that was most compelling to me was what are we doing for people and why are we doing it? And are we giving them a voice in their decision making? The other part of it is that as a writer, so much of palliative care, when I have conversations with patients and families, is really about understanding their story.

And a story is formed by words. And so as a writer, I was very compelled by how do we talk to people in a way that helps them understand what’s going on for them? And how do we understand where they’re coming from? So for example, if someone says, “I’m a fighter and I want everything done,” to me, as a writer and a doctor, I want to understand what being a fighter means. I want to understand what doing everything looks like or what they expect from that. So both from the bioethical and clinical patient care aspects of palliative care but also this close attention to language and story, I think those were both reasons that I ended up practicing in this field.

James Shaheen: So, you know, you mentioned when it’s appropriate and when it isn’t appropriate, say, to intubate somebody because so much of palliative care revolves around acknowledging our mortality, and you write that you were five years old when you first heard that life was temporary. So can you tell us a little bit about your religious upbringing? How did your parents teach you about death and impermanence?

Sunita Puri: Yes.  I grew up with parents who are very, very spiritual Hindus, and we also practice Sikhism and parts of Buddhism as well. It was kind of an amalgam. And both my parents are scientists. My mom is a doctor and my father is an engineer. But from a very young age, I saw the model that science and spirituality are not foes, that they can actually coexist really beautifully. And in that scene in the opening, my dad and I were having dinner together, something like I think Long John Silvers or something that my mom would not approve of, and she was on call. And so I was eating dinner with him and watching the sunset and it was so beautiful. And I asked him, “Why can’t the sky always look like this?” And he said, “The sky is beautiful now. And it will change because everything in life will change and is temporary and impermanent, whether it’s the plant over there or me growing old and getting white hair.

All things are subject to change, and the law of temporality is the law of life. So the more you come to inhabit or understand that principle, the less suffering you’re going to experience in life because you will understand at a fundamental level that if you attach yourself to something that is going to change, that attachment or having this very still image of what something is, whether, again, it’s a relationship or your body or something else in your life, if you cling to what is right now, you will not be able to move with the flow of life. And that is going to cause suffering.” And this lesson, when I went into medical school, there was absolutely no acknowledgment of any sort of limits, whether it’s in medicine or of the body. There was no discussion of mortality. And so I had come into medicine with this orientation and also with this idea that God and medicine are not polar opposites. They don’t have to be. And I was really in for a shock.

James Shaheen: You know, it’s pretty amazing how seamlessly palliative care brings both the scientific or medical into contact with the spiritual. So in other words, you’re handling both and the writing comes out of both. But how has your relationship to teachings on impermanence changed as you’ve spent more time with dying patients? 

Sunita Puri: That’s a great question. I think earlier in my career when I was a resident and I was born and then I finished and first started my palliative care training, this concept was kind of in my head intellectually. I could explain it to you, I could explain it to patients, but I hadn’t really inhabited it or seen my patients inhabit it because it wasn’t always easy for me to bring those sorts of concepts up. I think when you’re talking about anything philosophical or spiritual, you’re taught in your training not to go there. Even though in palliative care, spiritual care is a big part of what we do, sometimes that gets turfed to the chaplain, for example. But as I got more comfortable in my own way of being with patients, I started to ask them a bit, how have you coped with change in the past? What has been challenging for you in the different changes in your life? What have been ways that you wish you’d cope differently? What has given you strength as you’ve moved through change? How can we link the ways you’ve coped in the past to what you’re going through now, which is one of the most ultimate changes of your body and your spirit as you move towards the end of your life or as you begin your journey with illness? Because palliative care is involved from the beginning, ideally.

And I think as I’ve gotten more comfortable and I’ve seen patients respond well to this idea of impermanence, I’ve become more bold in going there. And so what I mean by that is I had a patient not too long ago who was this lovely gentleman, 75, who was dying of pancreatic cancer and had never really considered how he’d coped with change in the past and what was making this an even bigger challenge, which understandably it is. And so I actually talked to him about something I’ve written about before, which is the mandala, the Buddhist mandala. And as many of us probably know, Buddhist monks will come together and make this beautiful mandala sand painting, and in a ritual, they will then sweep it up and hand out little packets of the sand. And I think that is one of the most beautiful representations of creating something beautiful, not being attached to it because attachment’s the root of self suffering, sweeping it up and handing it out, and then eventually emptying that packet in the river. And so I talked to this patient about the mandala, and he got super into it and went down a rabbit hole reading about the history of mandalas. He got The Tibetan Book of Living and Dying. And it was all because I felt I wasn’t scared to go there with him at a certain point in our relationship. And although this answer feels very long-winded, I’m trying to trace the evolution of how I got to a place where this is a more seamless conversation than I had in the past. And I do think it helps people to reckon with that philosophy. 

Sharon Salzberg: In our larger American culture and mainstream culture, it can be so easy to talk around death rather than about it, to look anywhere else rather than directly at it. So it’s fascinating to hear one of the ways that you’ve learned to broach such difficult conversations more directly and I’m wondering if you could say some more about that and how it can be so scary for the person receiving this information.

Sunita Puri: Absolutely. So I think contending with mortality is the ultimate challenge in life. And in some philosophies, the idea is that all of life is preparation for death and for a good death and dying well. But we don’t have good language in our country about talking about even just suffering, let alone dying. And so we get into these conversations where death becomes this huge big thing that no one wants to talk about. It’s almost like the anxiety about it is worse than the thing itself. It’s worse than the conversation. And we talk here about, you know, being fighters and not wanting to quit and wanting everything done and awaiting miracles as if getting sick is some sort of moral failing.

And I think that that orientation in our culture, whether it’s broader society or within medicine, really stops people from having the beautiful conversation with themselves about what has my life meant and what will it mean now and how do I want to live as I’m dying? And I talk to people first by acknowledging how scary this is. We only die once. We don’t know what lies ahead. We don’t know what we’re going to feel. We want to protect our families. Sometimes we want to protect ourselves. And so I ease into it gently by acknowledging first what a hard situation people are in. And a lot of these discussions involve me gauging how people are reacting to what I’m saying or how they react to what they’re saying aloud, sometimes for the first time. So a lot of these conversations is reading the room. And so I advance the conversation based on what sense I’m getting of a person’s comfort going forward. And I’ll often start just by asking them what they know about their illness because a lot of people don’t actually know what’s going on.

They may think they have a curable cancer when in fact it isn’t curable. So information sharing is a big part of what we do. And then we kind of move into filling in the gaps about what they know or don’t know and asking them what they make of this situation. What are the things that have been hardest about it? When they envision their life moving forward, not just their dying, what’s important to them? And in that way, if we move into a conversation about living well as you’re dying, that can actually be a space of empowerment if it’s done well if people are open to it. Because you get to have a say about what you would and wouldn’t want based on what’s important to you.

Sharon Salzberg: You know, I don’t know if it’s still this way, but it seemed, at one point at any rate, like acknowledging death ran counter to much of standard medical training. In so many ways, it seemed that doctors were taught or conditioned to view death as some kind of failure. So just listening to you now, I’m thinking about how tempting it would be if that’s the orientation. Do you think it’s still that way? How do you teach clinicians to talk openly about suffering? 

Sunita Puri: That’s a great question. And I will tell you, I finished my training now ten years ago, which is hard to believe, but at that time there was really no curriculum, and it’s changed quite a bit in terms of medical students and residents and fellows and even people who are practicing attendings getting more training on things like how to manage cancer pain, for example, how to manage that suffering, but then also how to have discussions with their patients and families about these topics.

And those trainings, I think, have made a difference. The growth of palliative care, I think, has made a huge difference. But that cultural orientation toward keeping people alive, sometimes at all costs, even the cost of their suffering, is still very much ingrained in medicine. And so I think when I’m teaching my students, I teach them that all medicine or most of medicine is palliative because what is the point of medicine?

It’s to help people live well free of suffering, right? That’s why we put people through surgeries to fix something. It’s why we give people antibiotics when they’re feeling horrible and they have an infection. But the vast majority of chronic issues we cannot cure. We can’t cure heart failure. We can’t cure COPD, among other conditions. And so what we do is we treat symptoms. And treating symptoms is the core of palliative care. So I try to teach them through that lens that it is not your fault if somebody dies despite your best efforts. That’s not a reflection on you and whether you were enough of a hero to them. It’s a reflection of how disease looks as it naturally progresses despite all our efforts.

And medicine will never win against nature. And that’s kind of something I also teach my students. So how do you hold wanting to do your best for patients with respecting the limits of the body and what the body shows us when it’s nearing the end? Because the body is a beautiful work of nature and we forget that nature has the last word in medicine. So I try to help them see things in a way that’s not about medicine’s mission to fix everything but more about medicine’s mission to help people live well. And that’s why we have all of these interventions. And every patient you are going to lose at some point.

You will lose the people you love, too. So how can you learn all of the medicine that’s really important? Because the high-tech medicine is hugely important. It saves lives. It’s remarkable. And we’re very lucky to live in a country where we have good access to these things. But how can you hold that and the fact of loss and the fact that sometimes, despite your best efforts, someone will die or someone will suffer? How can two things be true at once? Can you cultivate a relationship to that? And that’s the inner work of being a doctor that we don’t get explicitly taught. 

Sharon Salzberg: I want to pick up also on something you were just talking about, the power of language that we use to describe illness, like calling someone a fighter or describing cancer as a battle, and I’m just sitting here thinking about the word courage and how, for many people, it might imply “Don’t be afraid ever,” or “Don’t have feelings, don’t cry.” Can you say more about how language can shape people’s experience of illness?

Sunita Puri: Certainly. So I think especially in the world of cancer, these ideas of being a fighter and not a quitter and doing everything and waiting for a miracle and being courageous and telling people not to be afraid, I think these are really common linguistic traps. And what I have seen happen is that people feel either like they need to do treatments or surgeries that they actually don’t want but they don’t want to seem like a quitter for their family or their doctors. That sometimes happens when we don’t give people a chance to slow down and say, “Tell me what being a fighter means to you. Tell me how you understand this fight. Tell me what you’re fighting for at this point in your illness.” And what you fight for early on will change because sometimes toward the end, what we fight for is comfort and quality of life. And when we don’t give people that space, we are sometimes putting our assumptions onto what being a fighter and what fighting means, and we’re putting that on the patient. Because to some people, being a fighter means trying every treatment until you die, and people really take that on. And as I mentioned earlier, I think we consider disease some sort of moral failing in this country. And so you can imagine that if you’re sick and you have that orientation toward disease, you’re going to want to do everything you can to dispel this image of you as somehow weak and vulnerable. And we don’t do a good job sitting with vulnerability in this culture either. And so whatever people can do to move away from that is what they’re going to do. I think the hard part is that we don’t do a good job of explaining that you as a fighter, as a spirit, are not, it doesn’t correlate to your body being able to fight. And that separation, I think, can be very healing for people to hear because you’re in it as a person, but your body’s also in it as a biological entity. So we’ll often hear oncologists tell people, “If you can get stronger, we’ll give you more chemo.” And “stronger” is never explicitly defined a lot of the time. And people feel like they need to change their nutritional habits, push themselves out of bed, push themselves to their limits because they feel like it’s mind over matter, and being a fighter means putting mind over matter at all times. But that’s actually not the case because their body cannot always fight. And so getting into the language is extremely important to really understand what people know and what they mean when they use these words.

Sharon Salzberg: I’m so curious also about how this very discerning use of language intersects with your role as a writer. How does being a writer perhaps influence how you pay attention as a physician?

Sunita Puri: Yes. So being a writer and being a physician, both things depend very heavily on observation. So when I go into a room and I meet a patient, I’m observing how they’re looking physically. I’m observing how they’re reacting to some of the questions I’ve asked. I’m very focused on particular things. And as a writer, you’re also taking what you observe about human nature and putting it on the page. The things you don’t understand, the things you’re grappling with about why people do what they do.

When people are under pressure, how do they react? How does that help you understand how to portray them on the page as a character? How are your own observations of your nature going to make you a reliable narrator if you’re writing in the first person? And so the link is observation. And when I go into a family meeting, for example, I’ll teach my students and residents, I want you to think of this as an essay. What are the two, maybe three big things that you want this patient or family to take away from this discussion? How will you structure the conversation to be sure you’re able to communicate those things while also taking in what they have to say? Because if you’re leading the conversation, you can think like a writer, but the people listening to you are your readers.

And so you have to integrate their perspective into this conversation, and I think that that is a very different orientation to the medical model of teaching about disease and how to talk to people, but by bringing a writer’s orientation into the room, you’re getting people to think about interacting with other human beings in a very different way. You’re asking them to draw on powers of observation that are not just physical but linguistic. And you’re helping them to bring an understanding of the arts into a conversation that has huge medical and other implications. And so being a writer absolutely influences how I think about doctoring and vice versa because how I doctor makes me a better writer because it forces me to observe things in a different way and to understand that if you put two people with end-stage cancer under the same spotlight, they are going to be completely different characters, completely different human beings in different ways. And how will you then take care of them? 

James Shaheen: Yes, Sunita, on a related note, you refer to your training in palliative care as a process of unlearning. Can you tell us about this unlearning? What was it that you had to unlearn? 

Sunita Puri: Yes. So in residency in medical school, you really kind of learn that survival is your goal. Keeping people alive, knowing which medications or which interventions to pull out in what situation, looking at somebody with end-stage cancer who can’t breathe as somebody who needs a ventilator. That’s the orientation we were taught, the orientation to patient care, the orientation to the use of high-tech medicine. And when I was learning how to talk to people about disease, what I noticed was that when we would round with our teams, we would have a certain conversation about how sick somebody was. But we would go into the room and not always be transparent. And when I would observe how discussions about what people really wanted for themselves took place, it was less about making sure people understood what they were going through and more about asking, “If your heart stops and you die, do you want CPR? Do you want us to bring you back?” Or “If you can’t breathe, do you want a breathing machine?” “Do you want another cancer treatment?” So very stripped down ways of having high stakes discussions and a lot of trouble being transparent because I think the other thing we learn in medicine is that you don’t want to be the agent of, you know, people losing their hope. And I hear that a lot: “If I tell them this, will they just give up and lose hope? I don’t want to destroy their hope.” So those were all of the things that among others that I had to unlearn. I had to unlearn that being transparent was a failing or that being transparent would scare people away and make them give up and lose hope.

I had to learn that I as a person and as a doctor had no control over how somebody is going to hear and receive and process information. My role was to do it compassionately and honestly, because honesty is the compassion. And then to be with them as they process what they’re going through. I had to learn that I had to sit and listen and understand where somebody was at in their understanding of their condition and their understanding of what they wanted for themselves before I could decide whether a ventilator was in their best interest. So it was a reversal. It wasn’t saying, “You can’t breathe. Let me put you on a ventilator.” It was, “You can’t breathe because you have, for example, end-stage cancer. Have you had a conversation about what’s most important to you?” And obviously in emergencies you can’t do this, but if it was nonemergent, it was really more about asking people what they knew and giving them a bigger voice in their care than I had before.

It was also learning to be honest, to sit with my own discomfort about the things I couldn’t fix because when you can’t fix something in medicine, you feel like a failure. At least I did. And now you’re sitting with people whose cancer you can’t cure. You’re sitting with people whose anguish you cannot take away. So how do you unlearn your own discomfort? How do you learn to be with uncertainty? Because you have to help your patients be with uncertainty. And that also is not something that we’re taught.

James Shaheen: Yeah, you wrote a piece for the New Yorker about CPR, how often CPR can be not an affirmation of life, rather a denial of death. So you’ve very beautifully described how you advise patients to make one of the biggest decisions of their lives, if not the biggest decision. We recently had the palliative care physician Tony Back on the podcast, uh, and he talked about how Buddhism shifted his relationship to the powerlessness he experienced as an oncologist. Does this resonate for you? How do you relate to powerlessness in the face of your patient’s pain and distress?

Sunita Puri: I think that’s a great question about how do you come to terms with what you can and can’t control. And medicine is about nothing if not control and precision. When I sit with my patients, just in true transparency, I struggle a lot less. with that feeling of powerlessness because I do feel there’s so many other ways I can help them if I can’t cure things or take things away. I think we all have the power to witness. I think we have the power to accompany. And I think we have the power to make space for people to share what it’s like for them to be powerless and occasionally for us to share how we feel powerless as well. So sometimes if I know a patient well, I will say, I’m so sorry that I don’t have the power to fix this.

Here’s what we do have some control over and sometimes that’s managing symptoms. Sometimes that’s me helping them to tell their family that they really don’t want treatment anymore or that they really do want treatment. And a lot of times it’s helping me help my colleagues contend with their own distress over powerlessness because there’s a lot of that. I’m sure Tony spoke at length about what it’s like to be an oncologist and having a lot of  tools available but not the ultimate tool of total cure for a lot of people. And so a big role that I take on and I think palliative teams can take on is treating the distress of our colleagues because they struggle mightily with what it means to feel like a failure if they can’t fix their patient. And so helping them to take that monkey off their back, helping them to soften their own perspectives on themselves, that’s a power we do have. And that’s something that I think can help them and their sense of powerlessness to be dispelled so that they can be more comfortable with the uncertainty and the distress of their own patients.

Sharon Salzberg: You know, also in, in sitting here listening to you, I’m struck by, um, well, my own conditioning around death and, and, uh, the difference, uh, you know, say when I was a child, uh, after the age of nine, I lived with my grandparents rand, um, They would have the habit. They couldn’t say the word cancer out loud in a way, always had to be whispered, you know, and clearly that’s very different than your own conditioning But whatever everyone’s background I think just is such a prevailing difficulty of being confronted with suffering even apart from that issue of can you control it can you fix it. You know, for me, that ability was really born and reinforced every day in contemplative practice and that ability to be in some silence and hang in there with discomfort. And I’m wondering, both in your own life and, and as you counsel people, what tends to play that role? 

Sunita Puri: So much of what you’re getting at is what it means to live in the present, to come back to the present moment, because that’s all we really have at any given time, and to be less future oriented and past oriented. And the thing that I offer up to patients, especially people with a tremendous amount of anxiety who have trouble staying in their bodies and being grounded, is breathing exercises. So, even if people, you know, will say, “I’m not religious, I’m not spiritual,” I’ll just frame it in a way that’s not, you know, related to yoga, for example, because all of yoga is coming back to the breath. But just what it means to slow and feel your body, to feel your feet on the ground, to feel your hands on your hospital bed, or to touch something that gives you comfort, like at home, your pet’s fur, your warm quilt, to hold the hand of somebody you love.

And when you feel your anxiety spiraling out, just coming back to your senses can be a really good way of grounding and staying present and taking deep breaths and breathing through anxiety and finding a comforting thing to say to yourself. That’s a practice that I will often share with people. So taking deep breaths and having something running through your mind, like I am loved and safe, or I am strong and healthy, whatever mantra essentially people can say to give themselves comfort. Between that and the breath, that’s a type of contemplative practice that helps ground people because when we spiral and we’re in our monkey mind and a thousand thoughts are coming nonstop, it shows up in our body. And I noticed at least for myself that when my mind is going crazy, one of the first things I do is forget to breathe. And so reminding people our breath is the only thing we have at any given moment that we can actually control. So let’s breathe together. 

Sharon Salzberg: Would you say a similar thing to a physician you were mentoring? 

Sunita Puri: Yes. And I, you know, in my role as an educator, I deal with a lot. of the distress of the learners who are seeing things for the first time, who are feeling powerless, who are feeling judged because they’re going through their training and their anxiety is understandably very high, as mine was. And I wish I’d had better tools when I was a medical student to understand how to be still when you were running around all the time, how to practice acceptance of oneself and love for oneself when you’re being judged all the time, and to understand that who I really am is not what I do, that I am not my job, that I mean something in this world much greater than that, and having that orientation and coming back to even that mantra, “I am not what I do,” would have been a huge help to me. And so I talk about that a lot with my students and trainees and even my colleagues who are very distressed and overwhelmed, that you matter in a larger way than what happens in this hospital. That still means you’ve got to do your job well, but just remember that not everything is this.

James Shaheen: Sunita, you’ve also written about contemplative or spiritual approaches to death itself, and you write, If death were not only a medical fact, but also a spiritual and sacred passage, then it would always have a certain mystery that was perhaps worth accepting rather than attempting to control. So can you say more about how you understand death as a sacred passage?

Sunita Puri: Yes, so, you know, in centuries past, we didn’t have Western biomedicine, and we had rituals for attending to the deathbed. Katy Butler, who is a friend and mentor of mine, wrote in her book, Knocking on Heaven’s Door, about the Ars Moriendi, which was a booklet that circulated in Europe around the time of the plague, and it basically gave instructions on the art of dying, which is, I believe, what Ars Moriendi means. And a lot of the prescriptions, if you will, were about family attending to the deathbed, inviting God in. There was really nothing about medications to provide. And so we’ve always, I think, in human history, regarded death in different cultures differently, but as a passage that can be just as sacred as birth.

And so I think that now, first of all, death is hidden. People die in hospitals and nursing homes more than they die at home, so we don’t, it’s not natural to see, for example, an older person getting sicker and an older person dying in one’s home, so we have, it’s become much more medicalized and hidden, and it’s less of a social passage, it’s less of a spiritual  passage because we’ve made it so medicalized, [00:40:00] but in reality, At least in my, kind of spiritual practice, I think of death as a changing of the form, but something doesn’t die, which is the essence of who we really are, in Hinduism, our soul or our atman.

And that that is always preserved and the body is a temporary vessel, but who we really are doesn’t die. And That brings me great comfort, and that is entirely spiritual. And so when I’m treating people who have those beliefs, inviting that into the room, I think, eases a tremendous amount of suffering, because I’m not just looking at them as a patient, I’m looking at them as somebody who’s much greater than their body and who’s much greater than their sickness and who has  spiritual or religious beliefs that can comfort them in the passage of dying, sometimes much more than my pain medications can. And I think again, telling people, and I’ll sometimes outright say, “Death and dying and suffering are not just medical issues. What do you make of that? Do you agree with me?” And you open it up for discussion, and inviting that into the room can be transformative. 

James Shaheen: You know, you’re around death a lot, obviously, and you say something or ask something that at first I thought might seem counterintuitive. You ask what it would mean to regard your own death with reverence instead of fear, or even to have gratitude for the transience of your life. So what does it look like to have reverence or even gratitude for our mortality? Because that’s not something people automatically come to, although it could make a lot of sense. 

Sunita Puri: Yep. I think what it means is understanding that nothing is a given, that things can change in a moment. How will I make the most of the life I’m living now? What are the choices that I’m making, and do they match up to really the truth at my core and the way I want to live my life? And I think that is a type of contemplative practice in and of itself, to remember that one day I will not be here. One day I will get sick and not be able to be a doctor. Who will I be then? Who am I now? What would my life mean if I couldn’t walk around anymore? And I think the reverence for death reminds me that if I want to do something, I’ve got to do it because I don’t know how much time I’ll have. And so that kind of brings me more into the present sometimes.

And I think about these issues a lot, especially recently when I’m thinking about these very questions. Am I doing what brings my heart lightness? When I don’t feel joyful, what is missing? Because I don’t know how long I have to feel joyful. Would it be worth it to call that person I haven’t talked to in a long time because I don’t know when the last time I’ll get to talk to them is? Because I don’t know when they will leave me? So I think that reverence for death is really that it forces us to live, to ask ourselves, How do I want to live? What would it mean to not be who I am anymore? And I do think that that is something that’s not a part of our culture at all. Well, maybe I shouldn’t say at all. It’s something I hope will become a bigger part of our culture because I do think when people ask themselves those questions, that they can actually change their lives. And we have death to thank for that. 

James Shaheen: Yeah, you know, as you speak, it occurs to me that we don’t really have to wait until we’re on the deathbed to ask these questions. And in the book, you talk about your passage and becoming a medical professional and you had no time for anything and you were wholly identified with this work. And I’ve been there and I think a lot of us have been there. And so it’s sort of interesting: Who am I if I’m not a physician? Who am I if I’m not a palliative care doctor? I can easily ask, when I retire, who will I be if I’m not an editor? Who would I be if I couldn’t walk? These are questions that can precede death by a significant amount of time. Can you say something about that? 

Sunita Puri: Yes, there’s so many things I want to say in response to this, but I think that when I consider these questions, I’m forced to really kind of consider who am I at my core? If I couldn’t do the things I want to do, if I couldn’t be as mobile as I want to be, who would I be then? And the other question, who is it that I have always been? What is it in me that is unchanging and will remain unchanged? And that’s really going to the core of the spiritual practice, and at least in my spiritual practice, you know, understanding in Hinduism and Sikhism and Buddhism, to some extent, that I am an embodiment of something much greater than me. And I’m here on earth as a gift to use this lifetime to get closer to that. And I think that is something that when you realize that who you are at a place of work is not who you really are, who you are in relationship to somebody else is not always who you really are. These things orbit our universe and influence and shape us. But who we really are at our core. If we strip away all those identities, it’s a really interesting place to go. Who have I always been, no matter what has changed around me? Who will I always be, no matter what changes around me? And how will I cultivate a relationship to unanticipated change, whether it be not being able to walk or not being able to practice our jobs? How can I cultivate a relationship to that that will make me ever more grateful for  what I can do now?

James Shaheen: That’s nice. Sharon? 

Sharon Salzberg: I’m wondering, first if you, find that working with dying patients continues to influence how you live your life. 

Sunita Puri: Yes. I think a lot about their stories, about the things that they couldn’t see coming, because a lot of people can’t see their illness coming. Some people have been chronically sick for a while, and so for some of them, getting a fatal diagnosis is not something that completely upsets their world in the same way as somebody who’s a marathon runner who has a massive heart attack could not see it coming. And everybody copes in different ways, so I’m not trying to say people with chronic conditions cannot experience that same shock. But it’s slightly different, is something I’ve observed. And so I listen to the shock. I listen to the trauma. I listen to how hard it is for them to adjust to a new normal. And that’s all types of suffering that actually precede death and dying. and I really try to continue to ask myself, what could be around the corner? If I died tomorrow, I know I’d be just a memo at work. But what would it mean for me to feel like I’ve led a life where I’ve done things that haven’t been as fulfilling as I hoped? And a lot of it for me is coming to am I privileging the right things in my relationships with other people? Because to them I will not be a memo. To them I will be someone who they love deeply. Am I loving people deeply enough? I now live in Massachusetts. My whole family is in California in Los Angeles. and it’s a constant process of reevaluation. Is this where I need to be right now? How can I cultivate love and gratitude for them at a distance? Am I doing enough to show them how much I love them?

And those are the things that my patient stories make me really think about. Their regrets make me think about a lot of things. someone recently shared with me that he himself is a physician who got very sick, and he was wondering what it all meant to have been a doctor only to not be able to fix himself and whether all of the things he’d done for other people might grant him some grace, whether God would bestow some blessings on him in his own journey with sickness. And a lot of what he regretted was not understanding how lucky he was to have the people around him who loved him no matter what, whether he was a surgeon or not. And so I really take those things to heart, and I have more in the past few years than ever before. 

James Shaheen: Sunita, along this theme, would you be willing to read a passage from your book?

Sunita Puri: Yes, absolutely. Let me just open it. I’ve often heard or read that people who are dying can teach us what is really important in life and what it means to live fully. But though my patients are dying, part of what it means to see them is acknowledging the many ways that they are still trying to live. Some are preoccupied with paying bills, still bickering with their spouses, still buying cocaine or clipping coupons for milk and produce. Dying hasn’t bestowed upon them the meaning of life or turned them into embodiments of enlightenment. Dying is simply a continuation. of living this messy, temporary life humanly and imperfectly. And even as they struggle and stumble, each of my patients offers a vivid lesson in accepting inexplicable circumstances and choosing to live the best they can.

James Shaheen: Thank you. Sometimes we can romanticize dying, and that feels like another way of setting it apart from our own reality. But the real picture is often messier. Can you say more about what this messiness has taught us about our humanity?

Sunita Puri: Yes, so I think the messiness of living doesn’t go away when we’re dying. And that’s kind of what this passage is about, that we retain our full complex humanity and that getting sick and dying doesn’t suddenly make us into people that we weren’t always. That who we are just shows up in different ways sometimes under different stressors. I think that a lot of what we expect of the dying is unfair. They’re not there to be our teachers. They’re there to be dying and living the best they can. And I had written a piece for the New York Times back in March about this concept of wanting to accept that we’re dying, as if the dying must perform for us a certain role of a teacher or a certain embodiment of acceptance so that the rest of us can feel OK with their mortality and the impending loss. And I think that even things like asking people who are sick, “What’s on your bucket list?,” these are kind of all part of our cultural script that demands that there’s some sort of shift in who somebody is or how they’re living their life just because they got sick, and for some people that’s true. Sometimes getting sick and being in the process of dying does make them more motivated to be a better person or to live their truth in a new way. So I’m not discounting the power of that for sure, but I think we can’t put them on a pedestal and expect them. To do anything other than to be supported and living the best life that they can. And the romanticizing of dying gets in the way of them getting to be the full people that they are. And I think that speaks to something that I think about a lot, which is authenticity. Are we letting people be their authentic selves? Are we being our authentic selves with others? Are we letting people be vulnerable instead of elevating them to the sage-like way of being where they need to tell us about all their regrets and how to live a better life? And I think we have trouble being authentic and with being vulnerable and letting other people be vulnerable because we don’t know how to sit with it. And being sick and dying is the ultimate vulnerability. And so instead of asking people to accept it in a clear, particular way that we define, how can we let them be who they are and ask how we can be most helpful to them?

James Shaheen: Yeah, you know, it’s interesting. I’m thinking right now of somebody in my late 20s, uh, a close friend of mine who was dying and I went to see him. And he didn’t have that much longer, but he said, how was work? And, are you still arguing with so and so? And at first I thought, are we avoiding something? But on those visits, I got used to small talk as part of what we do. And he really did want to know. He’s still alive. He wants to know. We don’t need to talk about heavy topics. He just wants to talk about this. And it was a very big lesson for me. You recently wrote an article for Tricycle, “A Gift,” on an experience where you were confronted with impermanence in your own life. Can you tell us a bit about the article? 

Sunita Puri: Yes. So I have been trying in my writing to push myself to a place of greater vulnerability. And that means moving beyond my professional identity and the struggles and the vulnerability I face in the hospital with actually the vulnerability I face as a person. And so I write about a relationship that was very dear to me that I thought was going to be the relationship for my life. And it suddenly ended. This person and I had been talking about getting married, having children. I’d never felt this sort of intense connection with somebody before, and he had told me the same, that he had not experienced that. And I was away for a week, and when I came back, he came over and said, “We shouldn’t be together anymore.” When people talk about the moment they’re told a bad diagnosis, that there is a  before and an after. And it was that sort of trauma for me because I just couldn’t understand what was happening. I had to ground myself. I had to feel the couch beneath me. I didn’t know what to ask or how to understand it because I was so stunned.

And yet when I looked back at the relationship, there was something, whether it was a higher being or my own intuition, saying, “Just remember that everything you have now is going to change.” And I did not really understand where that was coming from. It had never come to me in prior such situations. But it gave me a way once the relationship was over to grieve but also to cultivate a new relationship to this type of loss. I think so much of my work is about helping people come to terms with the incremental losses of being sick, so losing the ability to work, losing the ability to pick up your child, like losing the ability to go get groceries, things we don’t think about twice. But I could be with people in those types of losses, and I could not be with myself in these types of losses in my own life. I could not see the change, the inevitability of change in a relationship or in a person as clearly as I could see the changes and the impermanence of what my patients went through in the hospital.

And so for me it was a real lesson that, just as my patients can’t always see what’s coming in their health, none of us can see what’s coming in really any aspect of our life. So how will I learn to be better with being with change but also not clinging to a static image of what I think a person is, who I think they are in relationship to me, how a relationship can evolve. Because I did that. I thought that our story was a particular one, not understanding or remembering that the whole point of a story is change. We can’t tell stories unless something changes in the story, whether it’s ourselves or somebody else or a realization that we come to when we’re put under pressure.

And so it really made me go back to asking myself, How can I live better with this knowledge of impermanence that I’ve known from a young age intellectually? But we all know that knowing something intellectually is not the same as inhabiting it in your own life. And I’ve never written about a relationship before and when I was going through the motions, I thought I don’t want this to come across as some sort of Taylor Swift takedown of somebody because, as I write in the piece, I was culpable as well as two people always are in relation to each other. I was not perfect and neither was he, and I think that the trap was seeing that we were both changing and not knowing how to come to terms with that. And I’m glad I wrote it. 

James Shaheen: Oh, I am glad you did too. I’m glad we published it. So, you know, also in the article, you explore the power of surrender, the opposite of control we so often reach for. So how can surrender lead to freedom? 

Sunita Puri: So I think surrender and acceptance are both huge spiritual lessons of a lifetime. And even apart from spirituality and religion, we all know things change, people change, and understanding how little we can control of that is, I think, a huge lesson that we learn in our lives. Surrender doesn’t mean giving up. And neither does acceptance. It doesn’t mean saying, “Well, whatever, I’m just going to let whatever happen.” It means embracing that there are things you can do in a situation, and there’s things that you can’t. And coming to embrace that power does give you freedom because it’s freedom from the bondage of expecting yourself to have control over everything. Surrender, a lot of it is about being in the present and detaching yourself from the past and from future thinking. And it’s not easy to do. I’m definitely no expert in this at all, but I’m starting to practice it with more intention because when I do embrace the fact that there are things I can do and there’s a lot of things I have no control over, no matter what I do, it frees me to focus on what I can do. It frees me to focus on how I want to live right now amid loss. It empowers me. So far from being something that’s about giving up or just not doing anything, surrender is empowerment. It’s a choice we make to understand the difference between what is within our control and what isn’t. 

James Shaheen: Sunita Puri, it’s been a great pleasure. Thank you so much for joining us.

Sunita Puri: Thank you so much for having me. This has been great. 

James Shaheen: For Sharon and me too. So for our listeners, be sure to pick up a copy of  Sunita’s memoir, That Good Night, and to read her article in the November issue of Tricycle. We like to close these podcasts with a short guided meditation, so I’ll hand it over to Sharon. Sharon? 

Sharon Salzberg: Thank you. And thank you so much for this really inspiring conversation. Let’s just sit together for a few minutes. Depending on your circumstance or also just how you feel, you can close your eyes or not, and just observe, to begin with, the kind of emotional climate in which you are dwelling right now. What’s happening in your body, what’s your mood, your feeling tone. 

Thinking about these words we just heard, surrender, acceptance, and earlier, not judging, being an observer, see if you can bring your attention to the feeling, the sensations of your in- and out-breath. Just the normal, natural breath. And just think, this is life. This fragile, ephemeral experience. See if you can gather all of your attention, all of your energy, and just settle on one breath. And then the next. And if your attention strays to that difficult relationship at work or what seems like a petty concern, it doesn’t matter. Remember acceptance, surrender. This is what’s happening right now. This is the truth of the present moment. See if you can let go of whatever is taking you away and just come back to the simple act of feeling your breath. So thank you. 

James Shaheen: Thank you Sharon, and thank you Sunita. 

Sunita Puri: Thank you so much. What a great way to end a podcast.

James Shaheen: You’ve been listening to Life As It Is with Sunita Puri. We’d love to hear your thoughts about the podcast, so write us at feedback@tricycle.org to let us know what you think. If you enjoyed this episode, please consider leaving a review on Apple Podcasts. To keep up with the show, you can follow Tricycle Talks wherever you listen to podcasts. Tricycle Talks and Life As It Is are produced by Sarah Fleming and The Podglomerate. I’m James Shaheen, editor-in-chief of Tricycle: The Buddhist Review. Thanks for listening!