BJ Miller, M.D.: Struggle is Real, Suffering is Optional
“My goal isn't to not be afraid, my goal is to have a relationship with fear. So I presume fear is going to be part of the picture. So my goal is more to have a relationship to that fear so I can move with it so I can push back on it so I can learn from it. Um, and so it doesn't have so much power over me, but I, I've not, I've not met any truly fearless people. It's more that I've met people who understand their fear and have made peace with it.” So says BJ Miller, a remarkable doctor who specializes in palliative medicine and end-of-life care, which ironically means that he spends most of his time teaching people how to really live.
When BJ was an undergrad at Princeton, he climbed an electrified train car and ended up as a triple-amputee and long-term patient. Understanding the healthcare system from the inside out inspired him to go to medical school—and it also put him into a deep and reflective dance with mortality, fear, and what it means to lean into life. He has become a cultural sherpa, showing us all what this looks like. These days, he is the founder of Mettle Health, which makes palliative care more accessible: He offers virtual consultations and guidance for individuals and families dealing with practical, emotional, and existential issues.
He joins me today as we discuss his work on life, death, and how we go about handling the in between. Our conversation covers the cultural numbness to death in the abstract and the concrete fear that arises when death becomes personal. We forget, BJ says, that suffering and dying are fundamental and intrinsic parts of life. When we allow ourselves to acknowledge the many small deaths that occur throughout our lives—whether it be the death of a relationship, of a career, or of a way of life - we can use these moments to practice losing and letting go, gaining clarity around what truly matters in the process. The goal, BJ tells us, is not to be unafraid of the end, but rather to cultivate a love of life so big, that it encompasses death as well. I am thrilled to call BJ a dear friend, and am even MORE thrilled to bring this conversation to you as we contemplate the year that just was, and the year to come.
EPISODE HIGHLIGHTS:
Contemplating death and a fascination with life…(
Big deaths, small deaths…(
The illusive sweet spot of perspective…(
Stripping down…(
MORE FROM BJ MILLER:
A BEGINNER’S GUIDE TO THE END by BJ Miller
BJ Miller - What Really Matters at the End of Life - Ted Talk, 2015
One Man's Quest to Change the Way We Die - The New York Times Magazine
Follow BJ on Twitter
TRANSCRIPT:
(Edited slightly for clarity.)
ELISE:
Well, it's wonderful to see you again, even, even on computer screens, I am, as you know, such a huge fan of your work and what you stand for and the culture and your, good humor as you sort of coach people to get closer, um, to their death. And it's funny, I was just thinking about that this Joseph Campbell, that Joseph Campbell quote, which I'm sure you're so familiar with, which is essentially, “The conquest of the fear of death is the recovery of life's joy. One can experience an unconditional affirmation of life only when one has accepted death, not as contrary to life, but as an aspect of life. Life and it's becoming is always shedding death. And on the point of death, the conquest of fear fields, the courage of life.” I love that quote. It's you, it's you, and it represents what's wrong so much in our culture. You know, our refusal to look at the fact that what begins must end and that this isn't an up and to the right chart and we are part of a cycle of life. So you, you are that to me.
B.J. MILLER, M.D.:
Oh man. Wow. I'll try not to talk you out of that Elise. Because that is kind of really what I would aspire to. I mean, I really, I think maybe all of us should, or I dunno, should aspire to, but I, anyway, I, I do that quote is gorgeous. It reminds me there's, there's a similar sentiment from Rilke. It's basically says something. that’s similarly, um, it's basically like the idea is to cultivate a love of life so big that it, that it includes death, you know, that it, rather than the kind of loving death or getting kind of, I don't know that I love death, but I love life enough to, to love death too, in a way. And I think that kind of gets at it. Um, but also that quote is so good because, uh, it's a point that's made in there that doesn't get made enough.
I think in my line of work and those of us who do hospice and palliative medicine and, and yourself too, I mean, a lot of us who are just, you know, interested in the truth, interested in reality. Sometimes if we're not careful, the rhetoric sounds like, oh, you're gotta look at death because cause it's like, you know, like kind of arc our job is to push people's faces into this hard pile. No, just for its own, just because in the name of truth or something. Um, I mean, there's, that could be plenty compelling, but the better news is if you do deal with death, somehow, if you find your way to wrap your head around this part of reality, you must in the process come to a big old love, or at least a fascination with life. Like that's a great upshot. It's not just: Look at this thing cause it's true. Look at this thing because it will help you love your time. So that needs to be sung from the, from the mountaintops again and again.
ELISE:
Yeah. And that the fear, the fear of, you know, no one gets out of here alive, but the fear of the end means that you're just not really liberated to enjoy the rest of the movie. You know, you're already mourning something. And it's interesting. I think culturally, because not only do we mourn it, we're not we're death obsessed in some ways in our culture. Like we love watching people shoot each other and kill each other on TV. We're very numb to death. Um, but when it's at our doorstep or at the doorstep of someone we love, it's like the palpable fear. I mean, you think about COVID and the hoarding reaction, which is understandable but the fear response was wild. This fear of losing what you have, not getting what you need, that sort of grips us by the throat. And maybe that's just the animal instinct and all of us, but it feels like we are, we have culturally become so many steps removed from the process and we don't wash our dead. We don't even sort of, we buy sanitize meat, right. Shrink wrapped me. Like we avoid thinking about the cycle of life whenever possible. Um, and it's not good.
B.J.:
No, no we're living proof of that. I mean, we're all, we're all, we're living proof of that and that anxiety is palpable and it's also contagious. And even if you're clicking along alright, you're living in a world, you’ve got fear pinging around it all over the place. It's unprocessed, and unexamined and everyone's being whipped around by their own feelings or the feelings of others nearby. So yeah, I think we, I mean, I think we could probably take it on face value that we have a, we have a problem here, um, and an opportunity to this big old existential crisis of COVID, just like you said so beautifully Elise, I mean, just rattled off like a real clear way in which we sort of a clear picture of how humans do this day in and day out. Yes. We fear death. Yes. But then we do this other thing.
We cartoon make it a cartoon through video games or through film to kind of that, that gives us a sense that somehow we're dealing with death, cause look, there's blood all over the screen or, you know, but we put it into a cartoon, which is just another way of distancing ourselves from it. And your point aesthetically, I love this point, too. Like, in these micro ways, whether it's shrink wrapped meat or these small aesthetic ways that we separate ourselves, put all these little abstract degrees of abstraction between ourselves and an object or a thing, to the point where any emotion, or any meaning, or any potency, or any connection has been crowded out. And that's general, that's a very subtle thing. I think you're right to be stunned walking by a meat like the meat counter in a grocery store should be enough to really arrest you, but it's not. We get inured and it's just this daily junk in the background that.
But anyway, I'm going on and on, but your point is such a good one. Like then you'll get to the end of life where things are actually raw, where you actually have to look, and if you're unpracticed at that at dealing with that fear or surprise or that bigness, then you just get bowled over for it and you miss it. You missed the movie, like you say, and that happens a lot. Maybe this is a refinement, or maybe I wonder if you agree, but like my goal isn't to not be afraid, my goal is to have a relationship with fear. So I presume fear is going to be part of this picture. So my goal is more to have a relationship to that fear so I can move with it, so I can push back on it, so I can learn from it, so it doesn't have so much power over me, but I've not met any truly fearless people. It's more that I've met people who understand their fear and have made peace with it.
ELISE:
Yeah, no, I think that's an incredibly important point because to have no fear would to be numbed out and to be detached. And I think what's more important. And what things like this pandemic, or life in general can teach us is about the fact that there are life is full of yes, a big death, but also many small deaths throughout our lives. Death of relationships, careers, marriages, friends, diagnoses, way of life, et cetera. It happens all the time and we were not very graceful, as it were. We don't really talk about that. And so we don't have this culture of sort of, um, getting up again and again and again, and, and, and building some resilience, building that muscle, recognizing that, I mean, sometimes, obviously life doesn't go on, but for the most of us, it will.
And I think, I think fear, you know, I don't like the, I don't like feeling fearful because it, it puts me into a panic state. But it also, as you said, I don't want to die. I, it's not that I am blasé about death. But when I think about it, when I allow myself to contemplate it, I also get very clear about where my attachments are and what, what I really need, and what I don't. And, you know, it's very clear that my attachments are to people like my children, and my husband, and my family. And, um, my cats don't judge me.
B.J.:
I’ve got two of them.
ELISE:
But I'm not attached to my stuff. I, but I might've thought that losing my things would be the worst thing ever. Um, but I dunno, I think it allows a little bit of the nuance of what we really care about to come in and you walk people through that all the time.
B.J.:
Yeah. Yes, yes. And yes. Um, and so do you, in this way, I mean, you know that this is a daily practice for many of us, if we chose to see, I mean, your point about little deaths all over the place, um, is a really, really key, and in part, because first of all, I just think it's true and it's a nice way to really be true to what's happening. Um, a lot of people will say, well, death is this foreign, exotic thing that we can't know. And that on some level maybe, right, there's not, there's also, I've been around a zillion deaths. There's all sorts of. I don't know. I, I, you know, who knows, I can't say what's coming afterwards. I, you know, I, um, but I, it, there is seemed to be just in terms of our human behavior around it.
We do have zillions of practice moments in a daily way around loss. Um, like you're describing deaths of roles, deaths of ideas, deaths of relationships, et cetera. So those are all we have these zillions of practice runs. So this thing that is exotic and scary and foreign, it turns out probably isn't so scary. Isn't so foreign. And definitely isn't that exotic. I mean, it's about as normal as it comes. So anyway, we're, we're amidst it all the time. So kind of what you're pointing to is we don't have to be in this rarefied hospital with a crazy-ass diagnosis. You can just open your eyes to your daily life and this stuff's going on all the time. So yeah. So that's yes. Amen sister, and yes, it is true. This is what I do for a living too.
ELISE:
I want to talk a little bit more about palliative care, but first what you, you, when you were talking about sort of what happens next, and I have my own theories, I know that you have theories that are what they are for you to sort of stay open to whatever it may be, but what's also so interesting about death. And what we observe in nature is that that's what feeds new life, right? So, we always want to take ourselves out of the cycle, but you know, you look at the composting of nature, the decomposition that leads through the next season. And, um, we think about, you know, it's been my experience having, you know, gone through, uh, the, I think you could call it tragic loss of my brother-in-law when he was only 39, but he is still very present.
And, you know, I will argue to the death. No, but I will argue with anyone not only who knows whether he is, I believe he's energetically very present with me and I feel him and I talk to him, and that helps me. Um, it certainly hasn't obviated my grief. I very much would love to go for a walk with him in 20 minutes and talk to him on the phone. But I, he is very alive to me because he lives on in memories and conversations. We're talking about him now, I think about what he would do. So it's so interesting to how we get fixated on the permanence of matter. Like if the person doesn't exist in exactly the same way or that thing doesn't exist, then it no longer has any bearing on our reality, but we know that that's not true.
B.J.:
Right. Another stunningly, obviously true, not true thing. We can just like your, yeah. Our daily lives have ample proof of this. For whatever else death may be and whatever, you know, the part that I, I can't comment on is my consciousness, per se, and this sort of a sense of, I, me, BJ, I don't know what happens to that. But there are plenty of things we do know that are right under our noses all the time, just like you described with your brother-in-law. Amen. I mean, so all we can really say about death is that it's, it's a, it's a change that much we know, but there's ample evidence that all sorts of things continue on and back to your point. But I think that one of his key key takeaways these days, whatever your issue is, um, is coming around to this idea that we, yes, there's so much we can learn from nature, like you're describing this life and death things, just all in a swirl all the time, just look out your window. Uh, but the next step is seeing that we are, that we are nature. I don't know, it's a fascinating, I suppose we could trace it back probably to Judeo-Christian roots, but this idea that we somehow held ourselves out as distinct from nature. Ooh. Cause Ooh, that's a lot of trouble, that there's been some fallout from that. And it does feel like death is one of these things that reacquaints us with this nature. And that we can get started on right away. In fact, we really probably should. Um, I think it was ample proof of that.
Desperately. Um, I think it's Dancing in the Flames of Marion Woodman and Eleanor Dixson, and The Crone, which I don't know if you've read that book by Barbara Walker, it's like a 1985 classic. If you love it, it's about sort of the, the pulling “the crone,” this elderly woman out sort of turning her into a witch, kicking her out. And as part of it, our lack of veneration for initiation rituals and even, you know, dying I think is at once, we're not procreated we're of little value. But Marion Woodman and Eleanor Dixon, they equate sort of that they equate it to the plague. Um, and being the first moment when death became this terrible specter that could not be controlled. And obviously it has roots all over the place. It's like Hobbs, it's Freud, it's this idea of like our minds.
We can suppress the body, we can suppress nature or natural urges through our minds, which is where so many of us are stuck, disembodied and not really having a full experience. And it is Judeo-Christian, it's just like, oh, we can get over all of these earthly temptations and delights we'll really get, will really live BJ. Like we're going to live in heaven. So odd. Yet, hen we also are like our death, the death might be the narrow gate to heaven and we still, we have no interest in going through it.
B.J.:
Right. Sorry, I just love that last point. Like, even if we stick with that tradition, that way of thinking it still doesn't add up. I mean, you still should be looking at your death either way.
ELISE:
So I’m a huge fan of your sort of practical guide to death, because I think that that's the greatest act of love is being really clear thinking about this, embracing it in some ways, not again, doesn't mean that you've overcome your fear of dying. And I think everyone needs to do this, whether you're 20, 30, 75, 95. But to keep a Google doc, keep a working document of what you want, where your stuff is, passwords. It sounds so strange. And, but having gone through this process, it is so loving. And hopefully you won't need it for 50 years, but to actually…one of the worst things in the aftermath is you're dealing with grief. And then you're also sort of like, how do I honor this person? I don't know what they want and how they want to be celebrated, what music they want to hear.
And it's a really, actually I've done it now. And it's a really beautiful practice to actually think about these things. And so I highly recommend that and I love your book. And as someone who's been there for so many people, both in palliative care, which I know we should talk about sort of as, um, not necessarily the end, but an important, very important resource for people who are dealing with long-term illness, whether it's terminal or not. But what do you see? Like what do you, what are the upsides like? What is the beauty of being there? Cause I know it's an incredibly fulfilling career. So talk us through what you observe.
B.J.:
Well, I mean, much of the upshot for me has been, um, reifying so much of what you're describing at least. And so much of what we're talking about here is, and, and things that I could have come to conceptually as a good undergraduate field of study or something, you know, you can, you can, you can look at death as an idea and its, and its impact in the world of as this construct that we bounce off of. And that's all fascinating, it's all really true. I mean, there's plenty to play with, you know, intellectually, but to then take this, these thoughts, and to watch them through real life embodied by real life. I mean, it's sort of embodied in real time experience to feel the feelings that go with all this, to know that something is actually about to really end, not as a thought, but actually, in it's matter. As porous, as we described earlier, as, as matter being, um, it is still significant, you know, there's still something very significant about death, um, just to sort of significant amount and just a quick tangent, I mean, mentioning, we were talking about other attachments earlier and other losses. Like I find, I still get a lot of, uh, glean, a lot of lesson out of the fact that I have cried just as much over lost animals and lost objects that I've loved, lost limbs, lost siblings.
There is something… those are not equal. It's a mistake to try to compare and contrast losses, I believe, but it is true that I just, those feelings, they're not so distinct, one from the other. And it's amazing how humans, how we get attached to things. It's a gorgeous enterprise. We just have to remember that the other end of it, that there's going to be a moment where we are asked to detach in some way. That's different from unattached. It's different from forget, it’s different from leave behind. But one thing I'll circle back to your question. But one of the things that doing this work does for you is you get, if you're, I think if you're, if you're watching, if you're being careful, you get much better at a very precious piece of this process, which is detachment, which is a letting go, which is a way of dropping your, your investment in a thing.
Like it's not going to pay you more dividends. It's not got some future payout with it. It is what it is and it's going away per se, and learning to learning to let go, learning, to drop into rhythm with people, learning to see what I get to hold on to and what I have to let go of that discernment. Those are beautiful. That's a lot I've gleaned from this work. So it's not been so hard for me in many humans, I suppose, to attach to things, to love something or someone in a way. But the other part of that love of sort of watching them go, letting them go ,and not, and, and not completely losing sight of life, or myself. That's a real practice. That's one that I don't think a lot of us are very good at because we move around at this pace, but I that’s one aspect of this work, but that's been very valuable for me. And it's very much a work in progress. I need to learn how to wind up into life. And I also need to learn how to wind out of it up and through. Like, there's a, there's a rhythm to all this. And I get a lot of practice at that, working with people who are, facing these moments themselves and I get to face them with them. So that's anyway, I'll shut up for a second. There's much more to say about this job, but that's it that's one piece.
ELISE:
No, I mean, and you're talking…that winding up and winding down. I mean, so much of that is we, and I don't know where this comes from. I'm curious to hear your thoughts, but this aversion to change, and this idea that somehow we can freeze this moment, or things won't evolve, or we won't become different people over time. Um, we're very scared of that. And you, I guess, you know, you're a living symbol of getting on an electrocuted train car and having your entire, your body, everything, completely be different. And I don't know if you are more joyful on this side. Um, I know you went through. it was very difficult obviously, but how do you think about that? Like that complete change to your body? And would you go back, would you tell that younger self don't get on that train car?
B.J.:
Yeah, I probably would. I mean, there are other ways to learn these lessons that are a little less expensive. But, but your point is still a good one. I mean, I have, so I, I always say that in part to not fetishize, uh, I don't want to, you know, I've, I've worked in places around people where I found there was a sort of ghoulish habit of comparing sufferings. Um, and who's, who's got it worse. Who's got it harder. I remember when I was in the rehab setting, like, what are you in for kind of talk? Like, what are, you know, what happened to you? Like the more outrageous the story, the cooler you were on some level. I mean, that's sort of an aside, but I also, but why to mention that at all is because no, I don't think, I don't think you need to have these very dramatic stories to learn these very simple lessons.
I happen to have had some drama, that’s sort of driven point home, but, um, but these are accessible. I don't want anyone to think that you have to have cataclysm befall you, um, in order to find, find a, kind of get through to these kinds of points that we're talking about today. But for me it was, I did need it. I didn't need a big old, I call it the cosmic-spanking. I did need just something to come along and to smack me really hard and make it clear that I wasn't so in charge. And also that it wasn't just, you don't have control kid. It was actually, no, it was more of like a refinement: Look where you do have control, look where you do have a say, and get really granular. And it was also a process of, you know, as a spoiled kid, of course, I thought there were things I wanted, to the point where I want I'm so bad, I thought I needed them. Then do you mean, do you use some language earlier in our conversation today that made me want to circle onto this point too. You're fertile and rich, Elise! There's so much to ping off with you. Um, did I just call you fertile? Sorry, sorry. I just mean, yeah, you, yes you are. And actually, I, I, I I'm with you. I, I think of this work that we do as actually a lot like fertilizer, but anyway, um, there is something really, really important. I think we get, we can't help, but start feeling so strongly about something that we want, that it becomes a need when it's not really a need. And I've watched that myself stripped down to the studs, and I got to see …it wasn’t like task master lesson, like I was saying before, like you better now, you know, you don't have any control.
It was more like, no, no, no, man, look now look, look at all that you can lose and still be you and still exist. Like that was a really juicy, great stuff. That was hard fought, and subtle, and came with a lot of pain, but that was a big, big takeaway. And that's that for me. And that's when I get to play out with others now is these sort of big existential crises come along, befall a life, they're inevitable. And when they do, they have a habit of, you know, shaking you down and loosening up the barnacles of you, these old habits, these old stories. And if you're, if you can roll with it, you get to shed a lot of poundage of stuff you're dragging along. If, if you, it can be overwhelming, it can be too much, but if you, if you can hang in there and I watch it happen with people again and again, they get to see what they actually just,what their need versus their wants, themselves versus others. Um, this control thing. So these are invaluable lines of sight and I get to see them all the time. And I got, I got ‘em early in life.
ELISE:
Yeah, it's, it's interesting, you know, living in California with fires, obviously. So we, you know, many years ago now we did a dry run evacuation. We sent our kids with their nanny to her house in Riverside, and then we packed some stuff, and sat in the house for a few days. And this is my husband and I, and we didn’t pack that much stuff. And then I was like, we have all this time. Should I be packing more? I was like, now, like, what am I going to do with my wedding dress? Like, I don't need any of this stuff. And then a few years after that, we actually did evacuate the fire. We watched from the hotel room, you know, we had our kidms and our cats, and some papers, and we watched the fire and it was, you know, our houses in the lower quadrant of where they were, you know, filming the fire.
And we were like, our house was gone, which is kind of sad because we live in a historic landmark architectural house yhat's very special. But that was the only thing that was that we were sad about. Um, in a way it was like, I guess it'll just burn and we will lose all of our stuff. And it doesn't matter. Like it was so liberating in a way it was almost like, let it go. I can't. I mean, when you talk about, you know, carrying around pounds of stuff, um, we get so fixed. You know, it's like, I don't know why I have all these things from my childhood. My mom doesn't know why, either she's very practical and likes to throw stuff away, but why. Tt's so it's wild, what we cling to. And I guess as you're working with people, part of that is as weeding out some of these attachments. And then as you say, like he was in the hotel room with you? It's not fun to be in a hotel room with cats, B.J. I will tell you that We're finding hotels that take cats.
B.J.:
Wait. So what are you guys are still living out of a hotel? Now? This is active now.
ELISE:
And no, a few years ago, our house didn't burn down, came very close, but no, we're not in a hotel, but it was interesting. I won't say it was disappointing because that would have been terrible, but in a way I was like, okay, I'm ready. Like ready… take it all. Um, except for my kids, and husband, and animals. Yeah. So it can happen and you must watch it happen. Like, is it a perceptible shift in people when they're really at the end?
B.J.:
Well, yes. Well, let me, well, that may make sure I get your question. So, I mean, one is, um, is it a perceptible shift when people begin to sort of letting go and sort of head into this sort of existential crisis? Or is it a perceptible shift when someone starts dying specifically when they start?
ELISE:
I mean, not even the dying, but the emotional cause the dying is sort of the physical reality. Right. But the emotional, like the, and I don't want to say lack of fear, cause I'm sure that's, as we say the constant plus point, but that the letting go, the starting to detach, and you're with people you're with both, both sides, right? The people who are devastated, but will continue to breathe. And then the people who won't. So what does that feel like?
B.J.:
Yeah. It feels like in some ways, and I can't tell if I'm inured to it, or it's just the, this is what this job, or if it's actually achieved, what word is, what it is we're talking about in a way, which is like: Daily life is filled with this stuff. Daily life is if you're paying attention, whether it's your own life, or your neighbors, or a bird on the tree that you're looking at, or whatever it is, there's ample evidence of what we're talking about all the time. There's ample evidence of just how precious, therefore, how precious everything is all the time, and how it could go at any time. So in some ways, like there's a sort of a mundane thing that happens around the end of life, too, because if you start seeing these patterns, it, it looks a lot like daily life, once your eyes are pried open.
So in some ways it can be these very stark moments with families. And those are often at the time of diagnosis, or the time of like hard news. Like, cancer has just spread or heart disease is just worsened. Some medical declaration moment that means your prognosis has just shifted, and it has significance for your future. So these are these big moments where people tend to where there can be some drama, and cataclysm, and can take a real moment to grieve the loss, to process that news, and to realize that you're still here while you are, and all that stuff that takes time, that takes grief. Um, but some, sometimes, or often the changes are much subtler. And I think we let these lessons into our consciousness as we can, when we can handle them. Like we're saying, we're seeped, we're surrounded by them.
So being with patients and families is in over the time, it's like watching a sort of, yes, it's watching a cascade of losses by some description, but it's also watching a gradual process of waking up or something like that. Of tuning in, in a different way. And so you've got these lines on the graph going in different directions and you get to feel both, but I can just say that to your question. It generally feels much more gradual than sort of these sort of big dramatic moments, like even my own with that injury in sophomore year of college. Like the moment itself, the injury itself was this huge Thunderbolt, And then the rehab, the lessons, I know we're talking about years of gradual, like a slog-fest. And so it is with patients and families. These are gradual moments.
Sometimes there's this set of real awakening in, in a moment, but that tends to get lost as real life kind of daily life comes back in and distracts people. So it's gradual, it's, non-linear. People will grasp these amazing, having these beautiful insights about themselves in the world, and they can feel really a peace. And then seconds later it's gone. That perspective, that sense of proportionality is elusive. And we have old muscle memories yanking us around, and the fears of others yanking us around. So you watch people move in and out of this sweet spot of perspective, and love, and everything is okay, but they don't get to stay that we, none of us had, seems gets to stay there for very long before being yanked off that circle. It just, so anyway, it's gradual. And in some ways in these ways, probably a lot, like I said, there's, there's something mundane about all that too. It's happening all the time.
ELISE:
It's interesting you say that because I also wonder if that's that revelation of the fact that it is mundane, it is like any other… in a way we, as much as we don't want to see it, we're used to this. It's like our bodies aren't are doing this. This is who we are. And so in a way, probably some of it must feel like, oh, it's, it just feels like this.
B.J.:
Yes, exactly. And it's not like, I think the lesson. Yes, I think the lesson is the takeaway is not like, oh, that's just as boring as life is. So like, no, like no, no, no. Open your eyes wider. Death is just as exciting …or life is just as exciting as this death is like, this is. There's something like, there's almost like a sin to being bored in this world. If you're bored, you're not looking. There's just, you know what I mean? I, and I say that with a little bit of a wink because I get bored. I don't mean to be so critical, but, but there's something about that. If you're not, if you're bored, you're not paying attention or something like that.
ELISE:
So let’s talk about Mettle Health and palliative care in general, because I know like not, not, it's not your intention to necessarily disrupt it, but that we have this culture that has, again, going back to like sanitize meat that sanitize the experience of death, right. People are terrified of hospice. They don't know what palliative care is. They don't know what's available. And then they sort of are in a death match with death, rather than allowing a more graceful, generous, spacious, loving…I would say definitely warmer experience, right? So can you talk a little bit about this next chapter?
B.J.:
Yeah. So, I mean, so first of all, it's just, like you said, I mean, for the, for, for, for your listeners, you know, palliative care and hospice get conflated all the time. There are a lot of reasons for that. But so palliative care is, is, is really, is very simply the sort of interdisciplinary pursuit of quality of life, or, you know, in the treatment of suffering. That's the novel, the novel distinctions around palliative care versus the rest of health care. Sohealthcare treats diseases, palliative care treats suffering, which is a sort of human subjective experience, you know? So we, we roll around with the subjective world. Whereas the rest of medicine is always trying to objectify things. In palliative medicine we're looking at the individual's dance, just the details of their experience. So our whole goal is to help us someone achieve quality of life in their terms, and to suffer less. That's that's all palliative cares about. And there's no mention of death. The hospice is a part of palliative care. It's a subset of palliative care that is reserved for the final months of life. Generally speaking.
So anyway, so hospice is yes. is a type of care that is needed out in the final say year of life. Whereas palliative care, I have patients I've been seeing in palliative care for 12, 13 years. Some folks who are even in remission, death is nowhere nearby, but they're suffering or they're trying to figure it out their place in the world, or they're trying to find their way to loving reality, which is basically my goal in life. So anyway, that's palliative care versus hospice, very important distinction, because like you're saying, you don't need to wait if you're suffering. If you're struggling, you got a hard diagnosis. You're living with some serious illness or your family member is, or someone you love is get palliative care involved. So that leads into Mettle.
So palliative care is a wonderful thing it's growing. Um, but it's not growing fast enough. Most big cities will have access to palliative care program. Large health systems generally have palliative care programs or regional cancer centers, big time medical centers, but it's lacking…the field hasn't grown big enough. You won't find that oftentimes in rural settings, there are certain geographies, the Southeast and Upper Midwest, there's not a ton of palliative care. Hospice is much more accessible, but like we were saying earlier, that's really for the final months to year of life. So it is just not very accessible. So Sonya my business partner and I decided with tele-health on the rise in a pandemic in the air, we started Mettle Health, we make it more accessible.
So you can reach out to us without a doctor's referral. You don't, you can be the patient, you can be a caregiver, you can be a family member, um, because we've pulled it out of the healthcare system, out of the medical system, we don't have the same hoops to jump through. Um, technically we're a social service, so I'm a physician, but in my new role at Mettle Health. I'm not wielding my prescription pad. I'm not becoming your doctor rather I'm coaching you how to use your doctor more effectively, uh, for example. So anyway, there's some wonky details about our structure we can talk about, but that's, that's Mettle Health. It's online, palliative care counseling, and coaching. And we talk about the full gamut. We talk about all sorts of stuff. Clients reach out to us. At least it's been fascinating. Some folks have been reaching out just because they're going through big transitions in their life. And they wisely see that palliative care has something to offer them like folks who are thinking about coming out of a marriage, or changing their careers, are looking for meaning in their lives, or those folks are also reaching out to us, which has been great, fricking love it. And it's allowed us to totally de-pathologize illness, difficulty, disability, death, even because as we've been talking, those are normal parts of a normal life and we're just treating them as such.
ELISE:
So it's very exciting. Cause I, you know, one of the things that, I mean like your work in general, lights me on fire, but this has been something that I've been thinking about, not compulsively, but just this idea of, of how we're asked to sort of resurrect ourselves again and again throughout life. And there's no structure support. And typically we go through these experiences, which can be, as you mentioned, the loss of a pet, or a natural disaster, a diagnosis, death, losing your job, getting divorced, whatever it is. And we're doing it not only typically alone and not timed with anyone else. But these things are scary to people. You know, they assume they feel like there's something maybe contagious about it, or contagious about the grief. There's so much shame around so many of these, and there are amazing resources, they're just scattered and people don't, it's hard to when you're in grief or in this moment of transition to know where to look, it's not, you're not at your finest. That's why I love to this idea of proactively preparing for these things right now.
B.J.:
Yes. Right on. Planning is important and that's what that whole book is about. A Beginner's Guide to the End, is sort of getting yourself prepared. Um, like we're talking, and planning is important, and just like we know in life, it's also important to realize like the plans only get you so far, and you got to learn how to roll with uncertainty. You have to learn how to move when the world underneath your feet seems to be unstable, you know, and these, uh, so that's, that's ultimately really so much what we end up talking about with folks at Mettle Health or in palliative care in general is you end up describing the experience of uncertainty or not knowing yourself. That's, those are the details of dealing with illness and death like that's and those are much more relatable. I think a lot of us feel those often oftentimes, um, you know, and having a place to reach out to someone who cause, cause he can feel so alone, it could feel like such a sad experience and such a lonely experience.
But it turns out these are variations on themes that all of us experience. And if you go to, you know, it's fun to just sort of set a safe place to talk about these things and weighed in, and look in, and lean into your life. And it's beautiful. I love, I love watching how people show up for these. We have these hour long sessions. It's just so fun watching how people show up and how vulnerable people are willing to be, and how the strength, one of the things, another cool thing on the long list of lessons I get to see play out in those, this false divide between vulnerability and strength, as though vulnerability is weakness. It's completely the opposite. I mean, if you're, if you can get vulnerable, you are, you are inherently strong. You know, there's something about..I've learned to really appreciate that this idea of strength is something that's agile and can shift and can move.
Like I find it. I think one of the greatest things we can do for each other in this life is be moved by each other, be moved by life’s experience by change, be altered by them, be sensitive to them. So here again, the idea is to allow ourselves is to actually exquisitely feel all these things and be with things, these feelings not barricade against them. That's not the way forward. You can't barricade against these things. These things are in you.
ELISE:
It’s everything it's cause it seems like the practicalities and obviously, and again, not to be comparative, but the practicalities of each situation are different in the, and but so much of it is the same, right? So much of it is about existential identity and what matters and then choosing, choosing a way forward.
B.J.:
Yeah. And I want to say something about that. Can I take another tangent? I'm just pinging all over the place. We talked a little bit about how the realization that so much, so, so much of the stuff where we spend our time does, does doesn't really matter. Yeah. It's so true and weeding out, getting clear about our needs versus our wants. Yes, yes, yes. But one of the great things about once you get clear on your needs and wants, I mean, I look, we still get to be neurotic, idiosyncratic weirdos. I mean, life seems to demand that. I mean, if I'm not feeling weird, I know I'm not in touch with life. I mean, life is weird. So we get to have our personality quirks. We get to have our, but just don't…so in other words, we get to have our illusions are once I have my, and we can have our fetishes, we can have all sorts of things. Just don't make the mistake of calling that a need. Don't pretend that you need that to be a valuable human being or to participate in life. So in other words, let's yes, let ourselves get stripped down now. And again, um, only to like, if you want to readorn yourself with all sorts of appliqués and chotchkies and distractions go for it, just call them chotchkies and distractions. That's my only point.
ELISE:
I think the other point worth making too, is that you talked about palliative care is as an antidote to suffering, which I think is really important, but we also tend to conflate culturally, suffering and struggling, and struggling is important. Life is of course it's hard. It's wonderful, beautiful worth it, but struggle is not the same as suffering. And I think sometimes we get a little confused.
B.J.:
Right on. A good life is not a life that is absent of struggle. That would be a boring life. I mean, there's something friction and we don't have to, you know, amen. Struggle is part of the deal. Just like fear is part of the deal. All sorts of tricky things are part of the deal. So the point here is not to inoculate yourself against pain. Part of the point here is, yeah, let's not suffer unnecessarily. Let's make good choices, but also let's get a lot better with struggling. Let's get more adept at the struggle. Let's find even joy in that struggle because that is part of this part of the deal. You wish that away, and you will have wished your life away.
ELISE:
B.J. Miller is a model for us all. He is truly one of the most compelling and charismatic and wise people I’ve encountered over years of interviewing hundreds of people. He’s one of those people who I feel like I could talk to every day and still get something interesting and new. He spends obviously, his life, contemplating what matters and helping people do the same. And then he lives in that way. It goes back to that Joseph Campbell quote that we talked about. For someone who faces death with people on the hourly, he has so much joy, it’s palpable…this, not detachment from life neecssarily because he clearly loves a lot of people, cats, and what he does with his days. But he manages to cup it in the palm of his hand, rather than cling to it. And it gives him a grace and ease that I wish we could all cultivate…it’s something I would love to cultivate in my life. Anyway, I hope you enjoyed that conversation. And as mentioned he has a practical guide to dealing with life, and also Mettle Health which is really trying to disrupt this idea that we have about end-of-life care as being scary, or ominous, or sanitized in a hospital. Noboy wants to die in a hospital, and nobody wants to suffer in a hospital. Hospitals are about acute care, not for healing in that way. And it’s really interesting to me that people reaching out to Mettle Health are not necessarily confronting health issues, but are confronting other existential transitional issues.