Grief, Loss, COVID, and lessons from the end of Life – Dr. Rohini Kanniganti – HPP 58

SUMMARY KEYWORDS

people, life, death, speak, medicine, dying, field, work, share, patient, grief, physician, peace, process, illness, conversation, trauma, hospice, moment, vulnerability

SPEAKERS

Dr. Will Van Derveer, Keith Kurlander, Dr. Rohini Kanniganti

 

Dr. Rohini Kanniganti 00:00

All along the way, there’s a part of us diminishingly along the path that kicks and screams and struggles and resists against it. We need an incredible amount of people to remind us that it’s okay. That this is exactly what we need to do.

 

Keith Kurlander 00:22

Thank you for joining us for the higher practice podcast. I’m Keith Kurlander with Dr. Will Van Derveer. This is the podcast where we explore what it takes to achieve optimal mental health. Today is a very special conversation. So buckle up your seats, we are going to take a deep dive into the conversation around death. And we’ve got an amazing palliative care doctor that we’re speaking to who’s been around dying people for a long time and we’re going to be exploring the deep questions here that most people have. What happens in the dying process? What do people have to face? How does it go well? How does it become very challenging? What’s grief? Why do we grieve? What does going through a dying process with family members, what can that do for us? What’s the opportunity in facing death? So it’s a conversation about death, and so it’s obviously if that for some reason is a conversation you don’t want to have, then this episode isn’t for you. But if it’s something you think about or have thought about and want to know more about, we’re going to go deep in here with this conversation and I was very moved by this conversation that we’re about to have here. And I learned a few things about myself here that I hadn’t known before. So I imagine you may as well. I’d like to introduce Rohini Kanniganti. She is a doctor that serves at the Denver hospice in optio palliative health services. She’s board certified in family medicine. Dr. Kanniganti has been practicing in Colorado for over a decade. Dr. Kanniganti graduated from Penn State University with a Bachelor of Science in chemistry and received a master’s in public health and her medical degree from the University of North Carolina. She’s known at the Denver hospice as the patient whisperer; bringing together the science and art of medicine, integrative approaches mindfulness and loving kindness to her work with people of all ages. Dr. Kanniganti lives in Boulder with her family. Let’s welcome Dr. Kanniganti to the show. Hi, Dr. Kanniganti. Welcome to the show.

 

Dr. Rohini Kanniganti 02:49

Hello.

 

Keith Kurlander 02:50

It’s great to have you on here.

 

Dr. Rohini Kanniganti 02:52

It’s wonderful to be here with you.

 

Keith Kurlander 02:54

So we’re going to start off with kind of just learning a little bit more about you. We would love to hear, this episode is really going to focus on the death and dying process and a lot of your personal experience in, you know, the countless hours working with patients in this area and we’d love to just start off hearing a little bit about you and what got you interested in this type of work.

 

Dr. Rohini Kanniganti 03:21

I’m gonna just enter this field with some gratitude, to be able to step in and share this with you. I also want to offer gifts of gentleness, of love in this really extraordinary time we find ourselves in and to offer to whoever’s listening, that if what I am saying, if the words feel too conceptual or abstract, or even too based in conclusion, and opinion to release that and to let it go and simply receive the tone, the love, whatever is coming through, receive that. What got me into this work, when Will and I first met, we had lunch somewhere in South Boulder and I said you want to play? And so, it doesn’t feel like work to me. I think that I’m a sculpture in the making then the maker is just chiseling off the extra bits until it turns into full on play. And it’s strange to call end of life work, play. But, you know, I’ve come through being a researcher, a scientist, med school, Family Medicine, more holistic and integrative in nature, through the help of mentors into this incredible field, where I feel finally at home, it is sacred. I get to say love a lot and I get to practice love a lot shamelessly. And this is the field in medicine where we’re really blessed to practice consciousness. There’s this amazing poem by Rumi. It’s called the worm’s waking. This is how a human being can change. There’s a worm, addicted to eating grape leaves. Suddenly, he wakes up. Call it grace, whatever, something wakes him. And he’s no longer a worm. He’s the entire vineyard in the orchard, to the fruit, the trunks, for growing wisdom of joy and wisdom that doesn’t need to devour. And this is play. That’s the field of play. And each day that I engage in this field, I feel more more intimately engaged in a conversation with the divine. And I have tears coming. So that must be so true.

 

Dr. Will Van Derveer 06:09

You know, as a fellow physician coming up in the western model, this devouring that you’re talking about reminds me of the aggression that we have toward disease, what we call disease and illness. And, yes, it sounds like you’re pointing toward in the work that you do a very, very different way with people. I wonder if you could share more about what that’s like for you?

 

Dr. Rohini Kanniganti 06:41

It’s incredibly intimate. And you both know this because you’re in a very intimate field yourself. And you made that choice to move towards that. Hospice is so blessed that it is a team working for a team. And in the rest of medicine, one can’t help but feel the separation that is the root of human suffering, right? But end of life care, whether it’s palliative or hospice, and it really magnifies hospice as a team of us, with nurses and physicians and nurse practitioners, chaplains, social workers, CNAs volunteers and others, administrators, right, who are so important. The infrastructure, working with not only a patient, but also their family and other beloved ones. And pediatricians know this, you know, those of us who go into feeds or med-feeds or family medicine, we’re taught that the patient on their own is not the unit and it’s incredibly beautiful to engage with that. So when I stepped into what feels like the field with the patient and their family, there’s this little butterfly effect. When I touch with love, a piece of that unit, that team, everything else shifts. And it’s amazing to see that. And so I enter every situation, carrying an extraordinary amount of love that doesn’t feel like it’s a learned emphatic skill. Something else that I can’t name that comes through. And as you know, and you know, there’s so much grief, and in this care, so much loss, and grief isn’t always pretty. It’s got hatred, and division. It’s got misunderstanding, hostility, anger, and rage. You know, we’re seeing it on the streets right now, and to be able to step in, and to meet that, with enormous courage and vulnerability, changes everything.

 

Keith Kurlander 09:15

Yeah. I mean, I am hearing just the profound sense of this undefinable love that seems to move through the process. And it has many forms as what I’m hearing.

 

Dr. Rohini Kanniganti 09:30

So many forms. Yes.

 

Keith Kurlander 09:32

So many forms and.

 

Dr. Rohini Kanniganti 09:34

It’s radical occlusion, right?

 

Keith Kurlander 09:37

Yeah. What are some of the big takeaways you have now from seeing so many different processes about that? You’ve mentioned some of them already. But I’m curious about just some of the big takeaways you now have about your own personal understanding of the dying process.

 

Dr. Rohini Kanniganti 10:00

Yes, you know, there are so many stories and one always starts in the present moment with COVID the sense of separation and isolation that people are feeling outside of hospice. Once we embrace people who’ve come in, suddenly we find a way of connecting people. But even there, we’re so limited. Yesterday, I was speaking with the husband of a patient who was in tears because he wasn’t able to come into the facility. Meanwhile, without him, she’s really dwindling. And the takeaway there with him, was entering with him into a place of surrender. We, you know, this is a hero’s journey. That’s a huge takeaway for me. And we all enter the hero’s journey, invited by symptoms or a catastrophic event, you know life limiting illness, for instance, COVID, the brutality in the world, and suddenly, we have to walk this path. There is no other way than to walk this path. But all along the way, there’s a part of us diminishingly along the path that kicks and screams and struggles and resists against it. We need an incredible amount of people to remind us that it’s okay, that this is exactly what we need to do. And so with this family member yesterday who I was speaking with, with FaceTime, I was able to say, can we hold together this reality of what is even if it’s uncertain, even if it’s tragic, this is how it’s happening. This is how it’s going down and I’m here with you and I can feel your heartbreak and ours are as well. And there was, you know, he was in tears. And at that moment, he transitioned from the tightness of frustration and anger into this brokenhearted open space where the light started to come right through. And you know just what I’m talking about. Both of you see that everyday in your work. And a few weeks ago, a dear friend of mine had a seizure, suffered a seizure, and suddenly he was in the ICU, and turns out, he has a brain tumor. But fortunately, he and I have known each other in the world of meditation, and he said, If I don’t stay in the present moment, it’s too frightening. And so we had the best spiritual date on the phone ever. We listened to an Eckhart Tolle lecture on dying before you die. There are so many takeaways. A few years ago, I started to ask myself, who are the people for whom this end of life is not trauma? And why not? What is it about these people that they radiate peace. And I noticed that when the person going through this transmits peace and acceptance, although, you know, if it’s not really authentically there, whatever is showing up authentically, that’s the most beautiful thing that there is. But these people, I was really curious when they exhibit this, everybody else shifts around them. And then it’s a party. It’s a party. It’s incredible. And we all keep going there because we want some effect. And I realized that there might be five iterative pieces that there’s five stages of embrace, of emergence, and that we encounter the story we tell ourselves about how death cannot be. And including to whoever’s listening, my question for you is, in this time of COVID, when we don’t know how this virus might affect us, is it okay to die? Is it okay to get dreadfully sick in this way? And there’s no right or wrong answer. We encounter our story. And whatever is happening in this moment, we allow it. We start to have open, alert awareness for it. It’s like coming into a new home, a new house, which you don’t know. And you take a seat and you start to bond with your surroundings. You start to belong to it. And in that belonging, there is more attachment than attunement. The beginnings of adaptation. Ayurvedic medicine says that the thrust of health is actually adaptation. And the strange paradox is that we can have cancer and we can have end stage dementia in which case, you know, where that example we don’t really have access to consciousness as the rest of us do. But somewhere, you know, COPD, heart failure, that as we start to move into that sense of belonging, that sense of I am here that the adaptation to that present moment actually makes us healthy. Strangely enough, that health is an experience of the moment. How we’re experiencing ourselves at the moment, in all of our multiple dimensions, right, the physical, the emotional, the social, the familial, the psychological, emotional, the mental, the cognitive, the wise and the emergent and so many more. And I noticed that as people allow, sit back, they become more procreative. They start to engage in an empowered way with what’s in front of them and speak for themselves. Self care really escalates the need, the capacity to ask for one’s needs to be fulfilled really increases. And this is where as a physician, I start to see somebody partner with their own goals of care. Eventually, I noticed that the story dissolves. The original story they came in with, about illness and their identity and who they are and a sense of even their own ground starts to dissolve, just like a caterpillar dissolves with its imaginal cells in a cocoon. And they start to become something that they did not expect to become and this is the beginning of the emergent process. And it’s always a continuum. We’re all there, and how magnificent it is to start that process before the life limiting illness hits, although there’s nothing wrong with starting it anytime sometimes our suffering and our pain and our grief was the opening, the opening to the door we’ve been waiting for.

 

Keith Kurlander 17:25

Do you find that many people face a review of the past or are many people facing the challenge of what’s to come or is it all the above?

 

Dr. Rohini Kanniganti 17:38

It’s a beautiful question of curiosity, right? And I’m still really curious about what goes on. We really don’t know, physically and mentally what I’m seeing happen and your birth and the birth of your siblings. I mean, each of our births is so unique and so it is with end of life and with death. It’s incredibly unique. But it does seem as though that if people have the privilege of time, and many of us don’t, we die in accidents or murders, suicides, other very catastrophic sudden events. But when we have the privilege of time, the neuroscience of this shows that when the brain feels threatened with its own survival, there’s a way in which there’s a simultaneous process of increased protection of certain experiences, and a stilling of the brain and an emptying almost, but before we get there, depending on people’s childhood experiences, and of course, this is where you as psycho therapists and psychiatrists come in, these experiences of trauma that are not held, you know, I don’t use the word resolve because resolution makes it seem like it goes somewhere else, as you know, it becomes a part of who we are. And any of this that’s not held and embraced, seems to start to come back up at the end of life. I see immense anxiety and agitation that early on, we might call post traumatic flashbacks. It’s as if people are fighting with demons, and even outside of the trauma landscape in the inpatient care center, persons at the end of life, you know, they’re in that comatose, unconscious state and the family wonders, why are they still here? They’re done. But they’re lingering. And we often share with them that people are likely processing at some level, just softly landing like a leaf falling off the tree, traveling through space and the air to come land on the ground. And I’m so curious other people pass away with a smile on their face. There is often at the end of life, people tend to look off into one specific point and when they’re conscious enough they speak about seeing deceased ones. This is a very common theme. Staring off. One patient’s daughter was watching her mother doing that and she says mom, mom don’t follow the light. Another very common theme is people speak about wanting to go home. And often the people around them and their families take that very literally. And, there is an increasing and great stilling that is fairly stunning. Of course we’ve got lots of awareness about near death experiences, about out of body experiences, the light, lots of people talking about the light. Steve Jobs, his last words at the end of his life were “Oh wow, oh wow, oh wow”. And it really gives me this sense that we may all or many of us, you know, again, I have no idea. This could be just an opinion and a conclusion or wishful thinking but it may be that somewhere between a brain process of shutting down and all that happens, perhaps, an activation of these centers in neurologic terms enter your cingulate cortex, the posterior cingulate cortex, the insula, the amygdala, prefrontal cortex, activated in these experiences and not dissimilar, interestingly to the experience of grief, which is also like a death internally. Maybe there’s a rush of serotonin increasing happiness. Maybe there’s endorphins. There’s no research that I found around that but this is all incredibly fascinating and humbling. We don’t know. And as much as we speak of consciousness, we don’t really know what that is. We don’t even know what a thought is, you know? Can I dissect your brain and find a thought? So, yes, the curiosity of what goes on for people, the life review, the settling in, the stilling, the emptying, it’s profound and really beautiful to be witness to that. And, kind of addictive. From the viewpoint of it bringing me back to my heart.

 

Dr. Will Van Derveer 22:55

It’s palpable the depths of your care and the sacred way that you hold the process that you get to be a witness and a participant in with these families. And you know, it’s been a while since we connected and talked about the practice of medicine. And then I’m wondering about the time since we last talked, because we’ve talked a lot over the years about the spirituality of practicing medicine. How have these experiences in the death and dying process shifted your perspective about what medicine is? I’m wondering if you could share, you know, with our audience, what if you went back let’s say to ordinary family practice, what would be different about how you would work with people today having had these so many profound experiences?

 

Dr. Rohini Kanniganti 23:52

It’s a beautiful question, Will. You know, I want to share this quote by David White who’s also a shared love, I think. He says in refusing our vulnerability, or refusing the help needed at every turn of our existence and immobilize the essential title and conversational foundations of our identity. The only choice, the only choice, the only choice we have as we mature, is how we inhabit our vulnerability. How we inhabit our vulnerability. And this is, I was already in that field of awareness and family medicine and it would be even more profound now because that vulnerability is the day to day losses, the day to day deaths that are preparation for the great opening, the great emptying, and to really, you know, promote this idea that this is all a hero’s journey, and that it’s an enormous privilege to walk in that I want to change, to help change the perception of illness as crisis and emergency, you know, the military model medicine that we’re really seeing right now into, from emergency to emergence. Huge shift in paradigm. The ABCDEs I spoke about a few minutes ago really came from my looking at the ABCDE of resuscitation in the emergency department for trauma. I want to share with you a poem that came through me with the help of the beloved last night. I called it war in peace and this kind of reflects what I want to share with all of us at this time. Our panic is a firehouse. Our panic is a firehouse with words of war. Our panic is a fire hose with words of war, frontline, heroes, fight, lockdown, danger, rescue, survival, failure, crisis, pandemic, death count, wars within wars, ruptures of humanity and still, and still God rises like Maya Angelou offers warm butter chunks of reassurance, medical nectar interactive ideas of peace and still God rises like Maya Angelou offers warm butter chunks of reassurance, medical nectar, iterative ideas of peace. It’s okay. It’s okay. All as well. All this well. We got this. We all got this. Traditional Medicine sees death as a failure and illness as a failure. What if it isn’t? What if it’s exactly what we need at this moment to wake up. To wake up to how beautiful we are, to how amazing we are. One of my favorite teachers, Matt Kahn says something like, If love is the highest vibration, why not clear everything else from the table of consideration and offer the embrace to the one who’s calling out for it.

 

Keith Kurlander 27:41

I often have these conversations, like all these little doors opening in my brain, and this one is really opening a lot of new doors for me. I’ve spent a good deal of time contemplating death in my lifetime as a part of the path to waking up and there’s something new for me in the conversation today about really seeing how much. First of all, we avoid the conversation generally, in our culture, and how much the mystery of death is potentially something to look forward to. Just like the mystery of life. It’s just opening kind of a new doorway to me of like, wow, like the mystery of death is just as beautiful as the mystery of life and walking through life with holding both is, to me sounds like a much more empowering path and walking through life saying I just want life and I never want that. To me, that seems like a very dis-empowering path, a very stressful path to live every day, since death can come at any time. So it’s just sort of opening that and I’m wondering about like, when you work with people and you help them in the process and like what do you feel is empowering relationship to this stuff to this concept of death that is maybe the greatest mystery we’ll ever have in our lifetime is this concept of death. How do you work with people around that? And what do you feel like at this point for yourself is a healthy way to view death.

 

Dr. Rohini Kanniganti 29:26

Thank you for asking that and thank you for being so beautiful, that you’re so open to exploring the new, undiscovered territory. And let’s play. I want to invoke a personal experience and you know, because here I am in hospice and end of life care. My father had dementia in the last 10 years of his life, and also a physician, a pathologist. I was not his primary decision maker. So I had to very respectfully stand aside, though my own feelings about the end of life is don’t take me to the hospital, don’t intubate, let it happen naturally, and peacefully. And, again, there was no right and no wrong. Things unfolded exactly the way they should. And the way they did. One of the things that we’re finding in COVID right now is that families are separated from their beloveds as the beloveds are passing away. And this has been very heartbreaking. And I feel such deep compassion for those who are dying alone in hospitals and facilities, you know, on events. And without invalidating that experience at all with the deepest of compassion, I want to offer that this goes on a lot. We’re often separated in the way that we live from those that we love who passed away. My father developed multi system failure in his body from an infection. He just went up in flames. Everything failed. He was taken to the hospital. He was in India, and I was here. And my sister is in Florida and another sister in Paris. My mom was with him and he ended up intubated, and alone. And I was communicating with, you know, on text and phone with my aunt, who was sitting next to my mother in a different place. And she said, I think he’s declining, or something of that kind and I immediately recognized what was going on. So I said to her, can you, my sister was on the phone with me, I said, can you please run me down to the ICU and put the phone next to him? She said, he’s not conscious. I said it doesn’t matter. He can hear me. And this is the magic and the mystery that we see at the end of life. So she did what I asked. I got on the phone and I shared with him the things that I always share with my patient’s families, to share, to say, to speak from the deepest sincerity of the heart. Dr. K’s high five, I love you, thank you so much for having been my father. You were an amazing father and I’m so honored. It’s okay for you to go. It’s okay for you to let go of your body. We’re going to be okay. We’re going to look after each other. These five things seem to be our chemical magic words. Then after I spoke to them my sister who I think was always his favorite, got on the phone and said similar things in her honey tone. She’s pure embodiment of honey. And, then we thought that the phone disconnected because it went silent and we didn’t know whether to hang on or call back. And then the ICU doc came on the phone, and she said, he just passed away. And, you know, it was like, Yes! Yes! We did it. We did it, it is accomplished. And we immediately flew to India. And I have to say that I kind of pretended to cry, because I didn’t feel any grief. I felt the splendor and the wonder of his completion. And that he was teaching me, and this is something I frequently share with families, is your loved one is teaching you how it’s going to be for you. How it could be for you. They’re making it okay for you to go through this because you will. And, you know my father, during his embodied life was a perfume in a bottle. And that bottle had a pretty close lid on it. He was gentle, but very soft spoken, rarely ever said anything. It was after he passed away that the communication with him just expanded and I entered this liminal field with him, this limbic resonance that was so profound, and he has shared with me guidance about peace. The first thing he shared was he said, seek peace. And I said, what does it mean? Usually, it’s to find peace or rest into peace. You know, seek seems so active. And several months later, there was another conversation in that field, you know, I’m not delusional, It didn’t feel like that but I woke up in between sleeping and awareness, and he was speaking of the illusion of solid objects that are bonded together. But he says there is still movement in everything and enormous spaciousness, therefore, in anything solid, seek the peace that hides in every situation. So profound, so profound that the bottle opened and the perfume is everywhere. It is so celebratory. There have been other patients for whom every experience was a curious one in this process. I think at the last integrative psychiatry conference, I shared the story of this patient who developed brain metastases that were progressing very rapidly. He had gone blind a couple days before I saw him and I sat next to him, and I said, you know, he didn’t know who I was. I greeted him and he was blind, and I said, and I’ll call him Gabriel, I said, so they’re one, Gabriel. You know, you’re blind now. And he said, I know. I can’t believe I get to be blind before I die. I get to experience this. And everything opened up. Everything opened up for us and his family was sitting around and they were following his sense of peace and arrival. And I was, we were sharing jokes and laughing. I shared a really bad joke about the blind dinosaur.

 

Keith Kurlander 36:47

There’s a blind dinosaur?

 

Dr. Will Van Derveer 36:51

Now I’m curious. Would you like to share that?

 

Dr. Rohini Kanniganti 36:55

It comes from Jurassic Park. What do you say to a blind dinosaur or what do you call a blind dinosaur? I don’t think he Saurus Rex. And that’s the other thing. You know, in the end of life, there is so much laughter. There is so much when in these moments when we’re going from suffering, the resistance and the suffering of resistance to opening. There’s that immediate awakening, and we’re all laughing in that miraculous alchemical place. Everything’s funny. Sometimes.

 

Dr. Will Van Derveer 37:38

I’m feeling a lot of gratitude for you and in your heart and the way that you walk in the world and the example that I feel you provide to other physicians for finding the courage and the grace to simply be with another person in their, I could say catastrophe in their suffering and their everything, every state, with kind of a fierce commitment not to aggress on them or to bring, you know, to be very aware of your agenda that can come. It’s so deeply ingrained in us as physicians to bring our agenda. And, one thing I’m really appreciating in this moment is the heightened awareness about the agendas that we can bring with good intentions, right? But the way that we can diminish from the experience by being unaware of the agendas that we bring.

 

Dr. Rohini Kanniganti 38:39

Right. Daniel Goleman talks about when we don’t know what we don’t know that what we don’t know, you know, sets the stage and I think the model of sick medicine, which is simply a stage in our evolution and maturity, not my intention to be divisive or critical. We are simply where we are, but we cause a lot of implicit trauma. We don’t realize that our panic and our use of panic language, our use of failure language can so activate the very, very, very tender, sensitive nervous systems of people.

 

Keith Kurlander 39:18

Yeah. And that obviously creates more obstacles to living well. And wellness in the body is obviously the activation of stress and then the body is obviously not probably the best move for the immune system when trying to deal with some of these forces that we’re facing.

 

Dr. Rohini Kanniganti 39:42

Yes, and there is the move that we’re already making in medicine we have moved so far into coming into our own love and humanity, is the movement. Dan Siegel once talked about his conversation with his teacher when he said, what is the difference between illness and wellness? And his teacher circled the I of illness and the We of wellness, and we are emerging into the consciousness of we rather than the I imposing upon another I. And we got this. We all got this.

 

Dr. Will Van Derveer 40:23

You know, we like to ask folks on this podcast a final question. I think you answered the question before the question was asked. While knowing you I’m not surprised that you have the ability to do that. The question has to do with a billboard that everyone can see. What would you like, if you could put a paragraph on this billboard that everyone in the world could see, What would you like everyone to know?

 

Dr. Rohini Kanniganti 40:56

I’d like to have everyone know that we’re on a hero’s journey, and that we’re all heroes walking this journey, and that we do not walk it alone, that we are profoundly relational. That the reason a table sticks together is because all of those atoms and electrons are in relationship. And this is part of the miracle of our life, in this form, is relationality. And we got this together.

 

Keith Kurlander 41:33

Hopefully everyone hears that message. It’s a great message to send to everyone. Thank you Rohini so much for sharing, just very profound wisdom on an extremely, extremely important topic right now to be addressing with everything going on in the world. So thank you so much for coming on the show and sharing what you see.

 

Dr. Rohini Kanniganti 41:59

And thank you both so much for the field that you held with me. It’s so sacred and so, so sweet and so loving. We were talking about a very serious topic and yet, the underlying river was one of joy and curiosity, and a welcoming. Thank you.

 

Keith Kurlander 42:25

Now if you want more information from us on really great cutting edge material, videos, newsletters, audios, all kinds of stuff on how to optimize your mental health, visit email dot psychiatry Institute dot com. That’s email dot psychiatry institute dot calm (email.psychiatryinstitute.com). And that’s where you can leave your email address and we will immediately start sending you some really great information to help you further along the journey, whether you’re a provider, or you’re an individual just interested in this work of living a more optimal life. We look forward to connecting with you again on the next episode of the higher practice podcast where we explore what it takes to achieve optimal mental health.