What do we say to the Lord of Death?
‘Not today.’
― George R.R. Martin
How to Think About Your Own Mortality (Without Getting Depressed)
Dr. B. J. Miller on what he’s learned about living from a career in end-of-life care.
BY CLAY SKIPPER for GQ.
When he was 19, B. J. Miller, a Princeton student at the time, was on the way to a Wawa with friends when he decided to climb a commuter train near campus. “Just out on the town horsing around, doing nothing particularly crazy,” he says. “We had done crazier things.”
This time, though, was different: Miller was electrocuted when electricity from the overhead wires jumped to his wristwatch. The electrical burns were so severe that he ended up losing three of his limbs. It was that harrowing, near-fatal accident that drove him to go into medicine and, ultimately, palliative care, working often with terminally ill patients.
Now, nearly 30 years later, he’s co-written (with Shoshana Berger) a book called A Beginner’s Guide to the End: Practical Advice for Living Life and Facing Death. In addition to being a useful textbook on how to die—with advice on everything from what type of casket to buy to how to talk to young children about death—it’s also filled with the meaningful lessons Dr. Miller has learned about what truly matters in life from spending time with those near its end.
Miller recently shared many of those insights, outlining why accepting death as a reality (yes, we’re all going to die) can liberate you to live a better life now.
Why do you think we avoid thinking about death, this thing that happens to all of us?
To cut ourselves some slack, we are hormonally wired to run away from our death. We have an inborn fight-or-flight-or-freeze response to any threat to our existence. So you can’t just write it off as denial.
But on top of that basic impulse, we have gotten spectacularly removed from all sorts of things in nature, including death, the most natural thing there is. If you think about the last 100 years, as technology has advanced and as [we’ve developed] new ways to push back death and extend life, we’ve gotten very seduced by the idea that, on some level, death is almost optional: Don’t smoke, eat kale, and you’ll live forever.
Silicon Valley’s trying to solve it.
That’s what we do. We make something normal, we call it a problem, we pathologize it, and then we go to war with it. Sometimes that works pretty well, and oftentimes it works not at all. In the case with end of life and death, it’s a mix. Medical science and our understanding of health has advanced, and we are able to live longer, and we have pushed back on nature in all sorts of ways that I’m happy for. I am alive because of medical science. In college, I had electrical injuries and nearly died from those. Were it not for the Vietnam War and all that was learned about saving folks with burns, I wouldn’t be here today. But the bad news is we just keep orphaning this subject of death, and it becomes less and less familiar and then more and more surprising and gets harder and harder than it needs to be.
Then I also think we’re kind of in a moment where we are reacquainting ourselves with nature, and we’re realizing that it’s a zero-sum game. If we take from over here, it’s going to take from over there—this idea that we’re all interrelated, that the pollution I make in my own home is going to make its way to China and vice-versa. The whole world order is changing around this. Not to be dramatic, but it just feels like a reckoning: no matter what we do, we’re still going to die. We have to reacquaint ourselves with that very basic fact.
How long was the recovery from your injury?
I was in a burn unit in New Jersey at Saint Barnabas Hospital for a couple of months, and then in a step-down unit, and then in a rehab hospital back home in Chicago, where my family was from at the time, and then outpatient rehab. That was November, and then I went back to school the following fall. I had accommodated the accident by the fifth year, so it was a long, slow process. But in the early days, it was touch and go, like ‘could die tonight’ kind of thing. So that was very intense. All sorts of crazy pains. We could talk for hours about all the thoughts that came up.
But it did get me very, very interested in what it means to be a human being. Am I less of a human being because I had no feet now? How was I different now—truly different? Was I of less value? What was I going to do with my life? Who would care? Was I going to be in a relationship again? These were the kind of questions rattling around in my head at the time. But I sort of settled on this question of what makes a human being a human being, and realizing it wasn’t their feet. I got to start from scratch and build my life up again. That was hard, but, in a way, a wonderful opportunity. Any of us can do that all the time, but I had a big fat excuse to do so. That ultimately led me into medicine.
What were some other questions you started asking yourself in the weeks and months after the incident, as you were refashioning who you were and what you wanted your life to be?
I had a mother who had polio and had used a wheelchair much of my life, so I had a running start on what it meant to be disabled and the forces at work on you there. Early on, you’re really trying to keep self-pity at bay. I learned from my mom that self-pity is such a seduction. People are going to pity you. You’re going to pity yourself. On some level, it gets a sweetness from people. People will give you things. There’s an upshot to it, but it’s like a sugar high. It doesn’t last, and it’s a trap. Those early days were hard, because you’d be doing something that you knew you were not going to be good at, but you knew you had to do it. You knew you were going to embarrass yourself in front of others, but you had to do to it, because otherwise you were going to fall prey to this pity thing.
Then it became questions like, am I going to get laid again? Sorry if that sounds graphic, but, seriously, a 19-year-old sitting in this bed, like, my God, I did not know what to expect there. That was a huge question. Then, beyond that, it was much more philosophical. It was much more of a sense of identity: Who am I now?
As a privileged white Princeton student, I was pretty used to having a fair amount of control over my life in ways that I completely took for granted. Now, all of a sudden, this kicked my ass in a very powerful way. There were moments of deep insecurity, but a lot of it was just simply being humble and realizing, holy cow, I suffer in ways now that I had just not been in touch with, and so many other people suffer. I got turned onto the idea that suffering was a link between people, not this thing that pushed them away. It was this thing that joined us: every human being suffers.Most Popular
Then, when I went back to school, I changed my major to art history. That was one of the best decisions I ever made. I started studying art as this thing that humans do to make sense of their experiences. Making art is this weird essential thing that humans do. We are a very creative, adaptive species.
I remember in my first art history class, I was sitting there looking at statues that came up in the slideshow, these old beautiful statues that were missing limbs. They weren’t designed that way. They were just statues that got broken over the years, and here we are in this class studying these things and loving them and talking about how beautiful they were. I was like, “Oh, I look like that statue on some level. We like that statue. Maybe I can like this.” It was that kind of simple and direct and concrete. We humans have this ability to change our perspective. Much more than we can change the material world, we can change how we see the material world. Taking on that power was the key.
“No matter what you do, you are going to die someday… If you can just reconcile that fact and put it into your world view, then the pressure’s off in some way. Succeed, you’re going down. Fail, you’re going down.”
You would go on to work at the Zen Hospice center in San Francisco. I know, in Zen Buddhism, a big thing is about the way we cling to desires. I imagine it takes a certain type of person to go to Princeton—one who probably strives and clings. So I’m curious how your perspective on ambition and aspiration changed after the accident.
This was one of the great upshots of the experience. It was all this striving that got me to Princeton. Everything’s sort of future-oriented. Everything’s strategic, a means to some end. It’s a compelling way to pull yourself up and out and through life, but, boy, is it problematic too. You lose out on so much. I had a hunch in my bones that that wasn’t really a great way to live, but I was caught up in that.
So the accident was dramatic and profound enough that it forced me to be in the moment, especially in the recovery phase, those first few years. I just couldn’t think too far ahead in the future, because there was just too much unknown, and I was too clogged up thinking about this moment. Dealing with the pain. How was I going to move around campus, get to classes? It really taught me to be here now. But also, more existentially, realizing, holy cow, I could die tomorrow, I could die today, a couple minutes from now. Really knowing that in my bones, not just as this interesting thought, was such a gift.
At what point did you know you wanted to go into medicine?
This experience had been so rich for me, and it forced a maturation on me in some ways that I really appreciated. Sure, you don’t have to lose limbs to learn these things. Let’s be clear. But I had, and I really, really wanted to use these experiences. I started thinking about how I could do that, and so I looked into disability advocacy work, and arts advocacy work. But medicine lit up as this ambitious thing to try.
Now ambition, by the way, took on a different meaning. I was willing to try things and fail. Failure had lost its sting. It gave me such an advantage. I had a totally different strut when I realized I didn’t mind losing. It freed me up to just try things. Okay, I’ll try going to medical school. What’s the worst that’s going to happen? I’ll fail out or I’ll hate it. Then I’ll do something else. A thought like that a few years before would have just broken me.
How did you bring that playfulness into your life, that idea that failure wasn’t this terrifying thing?
It was kind of just rammed down my throat, because with chronic illness, disability, all these things, they’re just incredibly awkward. They make for incredibly awkward moments. Your leg falls off when you’re walking across the street or whatever. Really ridiculous things happen.
Did that happen to you?
Oh, yeah. My favorite was in Denver. I was running across the street, and my leg flew off. All this traffic came screeching to a halt. I looked around. My leg was 10 feet away, and the facial expressions that people had, they were so freaked out, because they hadn’t put the math together that this was a fake leg. They just really thought some dude’s leg had just flown off spontaneously. Some guy got out of his car and went and picked up my leg and carried it back to me and handed it to me with the funniest facial expression I have ever seen in my life. There was nothing to do but to laugh. It was scary, I suppose, but I was safe. It was just funny.Most Popular
Playfulness is a real balm. I think a key way to get there is if you really rope it into your world view that, no matter what you do, you are going to die someday. Because you are. If you can just reconcile that fact and put it into your world view, then the pressure’s off in some way. Succeed, you’re going down. Fail, you’re going down. So either way, with that end point kind of guaranteed, you’re safe. You kind of can’t go wrong. That’s the gist that’s made playfulness much more accessible to me, because I’m going down no matter what I do, so might as well have fun.
And then I got a service dog, Vermont. I had him for 11 years. Just watching him in the world was so instructive, how playful he was when he felt safe. And that was the key: If you feel safe, then you can play. When Verm was safe, when he was feeling good, he was the most playful, loving, ridiculously ebullient critter. It came easily. He didn’t see some broken person who was missing parts. He wasn’t comparing me to some abstract thing he thought humans should look like. I don’t know that humans are the highest species sometimes. He’s very advanced. He’s super in the moment. He’s not treating you like he thinks you should be. He just deals with what is, and we could all learn from that.
Having been around so many people who are at the end of their lives, what are the things that people actually care about at the end?
People get to let go of a lot of concerns. It does force more of a cosmic perspective. I feel this too—time and space took on different meaning. A hundred years is no longer a long time to me. When I start thinking about the stretch of life and life inside of me and outside of me—and I see this in my patients, too—you can’t help but get in touch with a bigger world view. Well, it doesn’t always happen. But it does feel very accessible to start thinking with more cosmic time. Even if you live to be 120, that’s a blip in the grand scheme. Sometimes it really challenges your ego.
But, in a way, it’s nice, at the end of life, you get to feel nice and small. All the little concerns that just drove you batty are in proportion now. They’re in perspective now. They reveal themselves to be small things. You come to a place of a grander perspective. You’re aware that, sure, this body dies, or this ego dies, but the life that this thing’s apart of keeps going. There’s so much more life, that life is huge, and that life’s going to keep going. You’re mourning your own loss, but you’re super aware that you’re reentering that cosmic side of things. That can be very beautiful to see.
It goes back to the art history, in a way.
Yes, because it comes down to how humans see themselves in the world, and that is a very subjective, squishy thing. We can zoom in and see ourselves very big in a small pond, or we can zoom out and see ourselves teeny in a little pond. The human capacity to choose your point of view is stunning. That’s our singular talent, if you ask me, and I watch people exercise that at the end of life.“When you start thinking about grief and its relationship to life, you quickly realize that grief and love are totally entwined.”
What have you learned about grief in your work with death that you’ve then used with other forms of loss, be it the end of a relationship or a job, or something like that?
If there’s one skill that we humans should really work on to kind of pull us through these times, I honestly think it’s grieving. When you start thinking about grief and its relationship to life, you quickly realize that grief and love are totally entwined. If you don’t love someone or something, losing it’s not such a big deal, right? So the pain, in a way, is directly related to your love. That connection, for me, has been really potent. It’s not necessarily a comfortable feeling. I think I would have, in the past, wanted to kind of kick it out of myself. I did this when my sister died. I didn’t give myself much grieving time, and I regret it so much. By trying to kick this hard feeling out of myself, I was kicking her out of myself. It was really a huge mistake.Most Popular
I think if I had learned this relationship to love, I wouldn’t have been so angry at these feelings. I wouldn’t have been so bothered by them. Then I would have probably rolled around with them. So normalizing grief, understanding that it’s going to have its way with you. It’s a surreal period, and it can feel off and hard. It feels off and hard, though, because you’ve lost a big piece of what constitutes reality for you, and that should be hard. I welcome that pain now, in a way, because it means I love.
What does feeling that pain look like? Just sitting with it?
Yeah. It’s not kicking feelings out of yourself. It’s actually daring to let yourself feel it, whatever it is. Do that. Then you’re not feeling guilty for feeling a certain way, feeling ashamed. “What’s wrong with me? I’m so sad.” The guilt and the shame, that’s this gratuitous pain that we kind of heap on ourselves and each other that is almost criminal. The instruction here is just let yourself feel what you’re going to feel. You can’t control it. It has its own life. It’s much more mysterious. That is to be welcomed, even if it is an obnoxious feeling.
Having come close to death, that was another early thought: Holy shit, I almost enjoy feeling pain. I don’t enjoy it. But I was just so glad to feel anything. Numbness is the enemy to me, not pain. If you go through it enough, you realize that you can withstand a lot. You can take it. In some ways, then pride kind of lines up with it too and all sorts of good stuff.
I think the whole key to so much of what we’re talking about, whether it’s grief or pain or whatever it is, just let yourself feel it. You’re not going to stay in grief forever. If you dare to revel in it a little bit, it doesn’t mean it’s going to stick around forever, that dark cloud. No, it actually is kind of the opposite.
If you don’t deal with it, it’s going to stick around and annoy you for years to come in indirect ways.