I’ll tell some stories about unfathomable finishes I have witnessed.

It sometimes defies physiology and logic.

Sometimes, the reason or underlying force of all this extra time spent at the threshold of living and dying can be surmised. Unfinished business, resistance, even anger.

Mostly though, the inner process of some folks, as they grind away impossibly at the clock and calendar, remains a mystery beyond anyone’s capacity to imagine.

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Barbara had really been through it. Treatment resistant triple-negative breast cancer for the last seven of her 73 years, she had undergone just about everything that the oncologists could throw at her. Five or six lines of palliative chemotherapy, even a bone marrow transplant following disfiguring surgery and radiotherapy that didn’t cure her. Two adult daughters with families, busy lives, and open hearts found their way to her bedside and camped out for her entire last visit to the hospital. She came with tumors in her brain and a lot of seizures and pain. Her son was on the phone alot with his sisters while critical choices were being made for their mom. A Chicago-based finance technology entrepreneur, her son Chuck was extremely busy, and by his own estimation, a very important businessman.

The decision was made to shift to purely comfort-based care and to withdraw anything that might prolong her dying process. Given that she was unconscious without any fluids or nutrition for a few days already, Chuck flew out the next day expecting death to occur promptly, She was only receiving was industrial strength doses of opioids to maintain her pain control now that she could no longer take anything by mouth, and extremely high doses of benzodiazepines to suppress seizure activity. All excess fluids were fastidiously removed from her IV. Nothing at all by mouth. Not a drop.

Death didn’t come quickly, and as those first days passed, he simply managed emails and phone calls on his cell in his noticeably stylish urban suit that became noticeably rumpled. He was often walking the halls of the unit, chattering a little too loud on his phone until the nurses ushered him to the stairwell where he was welcome to conduct his business. While his sisters understood the meaning of ‘presence’, Chuck’s restlessness was starting to aggravate his sisters.

By day four, he was hostile with his sisters and hostile with me and my metaphysical musings about why she might not be dead yet. He followed my suggestion to go grab some clothes at Target after an involuntary snort. I told him that the text books would have predicted death already, but that as real individual people approach their last breath , the textbooks, with their population-based statistical precision, have nothing useful to offer. There was only presence. A superior approach to waiting.

Days five and six passed. Chuck started spending more time in his decidedly not stylish Target t-shirts and sweatpants at the bedside. Days eight and ten passed, and he seemed to be less attentive to his phone and laptop. By days 15 and 16, he stopped anxiously asking when Barbara would die, and he began to repair years of estrangement with his sisters. On the 20th and 21st days, out came the photo albums. The grandchildren, and even her poodle came for a visit and a cuddle. I won’t describe her shocking appearance after three weeks with almost no water and no nourishment at all. The only sign of life was Barbara’s slow and steady breathing, which persisted while her family grew closer.

Equal parts tears and laughter filled the room. And something else. A tranquility and calm that was otherworldly and frankly spiritual, if you ask me, that spilled out of the room to all the nurses and staff that recognized the impossibility and awe of Barbara and her family’s process.

It was on the twenty-third day that Barbara’s life came to completion and her family was healed.

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It is my strong intuitive impression, from years of observation and witnessing, that Barbara was spending this time at the edge for some important work. Often, I have no idea at all what might be happening. Maybe, they are simply fascinated as they sit down and dangle their legs on the edge of the abyss and enjoy the view.

Our purpose is to attend. To witness. To serve with our presence and our love. Our challenge is to respect this process and to invite our own learning. To release them. To send them forward in their own time with our gratitude and our awe at the mystery of our shared existence.

As I write this, and my reason for putting this out today, there is another woman doing this very same thing at home. Two fat red cats, three huge dogs, two horses in the pasture out back, and her anxious husband that has begun to settle down after twenty days without food and eight days without a drop of water. (For those that are interested, she is daily receiving (via a rectal catheter): morphine 1200mg, methadone 240mg, and alprazolam 18mg.) The animals are calm, somehow knowing, and piled up on the bed continuously. Her husband is slowly learning about presence and loosening his dedication to waiting. He is getting used to my metaphysical musings about mystery and trust.

He seems to be settling his nerves and steadying his heart. Breathing and noticing the tranquility of the animals. And the sunrise. And the fog.

Psychedelic assisted therapies are undergoing a renaissance as a result of robust clinical trials emerging over the past 30 years with subsequent mainstream media coverage as well as from the enthusiasm of a subculture of our society that never stopped experimenting with altered states of consciousness. Recent rigorous clinical trials have focused on psilocybin and MDMA assisted therapies, laying down a strong foundation for safety and efficacy of these substances when combined with talk therapy. Two major Phase III trials with MDMA assisted therapy have shown compelling evidence of dramatic improvement in veterans and women with severe PTSD, such that more than 70% of subjects no longer met criteria for the disorder at the completion of the trials and intermediate term follow-up . Problems with functional unblinding (unsurprisingly, it turns out that the participants could tell when their consciousness was altered), the unprecedented combination of a drug with therapy, and some important ethical lapses led to deferred approval by the FDA this summer. Ongoing Phase III trials are underway with psilocybin assisted therapies as well as over 100 clinical trials actively investigating a wide variety of compounds and models of delivery for a wide variety of mental health conditions . Though no psychedelic drugs have yet been approved for this kind of use, there is growing interest and investment of capital, as well as clinical attention by mainstream psychiatry.

Of all these compounds, the only one being used legally in clinical settings is off-label ketamine. Ketamine was approved by the FDA in 1970 for short-term anesthesia and sedation. It has been included on the World Health Organization List of Essential Medicines since 1985, and esketamine was approved for the treatment of treatment-resistant depression in 2019 . With more than 50 years of safe clinical use, ketamine is well and deeply researched for the above indications and only now recognized as a legitimate agent for inducing extraordinary states of consciousness with healing intent. At much lower and safer doses than used for sedation and anesthesia, ketamine is being used effectively to address extraordinary disturbances in well-being for a variety of conditions that include treatment-resistant depression, anxiety disorders and PTSD. Given the freedom afforded by off label prescribing, a variety of practitioners are treating PTSD resulting from occupational trauma and burnout, in First Responders, as well as the care of people with demoralization as they face serious illness and the end of their lives.

While the psychiatric evidence base exists for simple infusional therapies and intranasal esketamine for treatment-resistant depression, the proliferation of models that combine psychotherapy with this medication are widely demonstrating greater efficacy and durability . At even lower doses, ketamine is proving effective at reducing or replacing opioid therapy for chronic and even malignant pain syndromes. Unfortunately, much less active clinical research is underway with racemic ketamine due to lack of potential profit making to drive the capital-intensive pharmaceutical drug development apparatus. As a result, combining ketamine with talk therapy is even less well studied than infusional or intranasal use of esketamine for treatment-resistant depression without the support of a psychotherapist.

It’s important to acknowledge the unusual nature of these molecules given their effect on the psyche, as well as their checkered history and impact on society. With regard to ketamine, there is a great deal of underground and recreational use complicated by addiction, abuse, and psychological harm. While this is almost entirely absent within responsible clinical programs dedicated to both efficacy and risk mitigation, stories in the popular press reinforce concerns about the substance itself and its dangers, while conflating street use with thoughtful and intentional therapeutic use supervised by dedicated clinicians . This is the same difficulty the public faces in distinguishing the abuse and addiction related to opioids from the powerful benefits from the ubiquitous use of opioids in clinical setting to treat pain resulting from trauma, surgery, malignancy, and in some chronic pain syndromes.

Responsible media and information campaigns can sometimes help, though unfortunately, the rapid dissemination of incomplete or even grossly inaccurate information spread thoughtlessly or with malicious intent can become a barrier to effective treatment for those in pain from physical conditions or those suffering deeply from mental health issues that would benefit from responsible clinical management by well-trained professionals accountable for safe practices that mitigate risk.

In addition to the accumulated knowledge and wisdom of traditional and indigenous practices that support healing, there has been a thriving underground guide community active for better than 50 years.These practitioners are a diverse and loosely networked group with connections formed organically and informally. For some, their experience and training may have been derived during a period prior to the War On Drugs when licensed psychotherapists were not forbidden to combine MDMA and related compounds with psychotherapy. More commonly, many guides have felt “called” by their own personal experiences with non-ordinary states of consciousness, with a few having had the privilege of formal apprenticeships with indigenous healers. Many have based their development as practitioners on self-study and inspiration from the clinical, philosophical, and metaphysical literature. Despite lacking professional accountability beyond their exposure by providing access to illegal substances, there exists some practitioners that function with remarkable effectiveness and a sense of responsibility to safely and ethically invite the best possible healing experiences for their clients .

Many such clients are seeking relief from the very afflictions that we attempt to address with mainstream healthcare. As we know, there is substantial variability between licensed clinicians with regard to quality, knowledge, dedication, and commitment to optimal patient/client benefit despite imperfect standardization of training, license requirements, and credentialing mechanisms. Our regulatory systems are designed to exclude and hold legally responsible practitioners that are dangerously unethical, incompetent, and exploitative. These systems are admittedly imperfect and stay busy reacting to harms caused by licensed practitioners after the fact, rather than preventing them.Likewise, underground practitioners run the gamut from extraordinary talent to breathtakingly dangerous, functioning with mostly absent oversight. Though efforts are underway to create certification and credentialing structures for licensed practitioners as well as legacy underground providers, these efforts have been hampered by difficulties with consensus definitions for the scope of proper training, the mechanisms for accountability, and appropriate experiential requirements that reliably begin to establish standards of care. Without such clarity, treating and referring clinicians must exercise discernment in evaluating individualized programs that ensure safety and mitigate risk, while optimizing access and benefit to vulnerable patients and clients seeking care. When seeking support for arranging psychedelic care in the underground, the burden for discernment falls solely on the person seeking these experiences.

Outside the narrow confines of service delivery within our healthcare system, a robust and varied landscape of psychedelic use exists. Local initiatives that decriminalize possession for personal use have emerged in a variety of municipalities across the United States. Statewide programs in Oregon and Colorado extend the decriminalization model for personal use to the development of regulated systems for facilitated use with elements of clinical accountability as well as public sanction for personal choice. As the whims of political will shift and change and the unforeseen consequences of well-meaning and popular legislation emerge, these early days of policy for psychedelic care have been characterized by dynamic and often unpredictable change. What seems clear is that our society is grappling with how it will incorporate a newfound acceptance of the safety and efficacy of these substances. It would appear that the genie is out of the bottle, with the real promise of healing for those that suffer and unprecedented impacts on our culture that seem beyond prediction.

The term “recreational use” may not be adequate to describe the real experiences of individuals taking these substances without facilitators or guides, outside the context of healthcare settings or spiritual communities. In fact, most psychedelic use takes place “for the fun” of it or informally as an exploration. Whether taken in nature, at a rave or festival, or in the living room of a friend, such experiences have had a great deal of impact on the perspectives, beliefs, and well being of the many people that explore them. Favorable and positive experiences are common, but not at all guaranteed. Outside of a controlled environment without intentional attention to critical aspects of screening, dose assessment of the mindset, and thoughtful selection of the setting for the experience, large alterations of consciousness can be terrifying and even traumatizing. In some rare and tragic circumstances, underlying severe mental illness can be unmasked and thrust above a threshold of quiescent potential to full full blown psychosis or mania.Even more uncommon are persistent perceptual disorders that can result from severe excess use and generate symptoms for many months, or even years. It is the responsibility of citizens, policymakers, and advocates to neither “throw out the baby with the bathwater” by hanging on to the prohibition we have inherited, nor to ignore the uncommon but real harm a small proportion of people experience. Harm reduction initiatives and networks of medical, psychotherapy, and traditional healers are taking form already, even in the absence of a coherent social and regulatory landscape.

While some people seek therapeutic healing within our healthcare system or enjoyment and adventure underground, there are many that find their way to working with psychedelic medicines as a spiritual and even religious expression. Protection of religious expression is in the bedrock of the US constitution and a reflection of the colonization of North America. Freedom to practice religion without fear of persecution drew many from Europe. Despite the dominant majority religion even though the separation of church and state has been an ever shifting dynamic, our legislature and Supreme Court have bent towards preserving a wide range of religious organization. The Native American Church’s use of peyote as sacrament is now protected, despite the long road to this current status. A number of church groups working with ayahuasca as sacrament also enjoyed protection through the courts, including two syncretic Brazilian Churches, the Santo Daime and UDV with branches and ongoing worship in the US. Most recently, the Church of the Eagle and Condor based in Arizona and bridging the indigenous traditions of North and South America have secured government permission to import ayahuasca from the Amazon for ceremonial use that weaves the wisdom and traditions of Shipibo and Navajo healers. The American experiment of legally protected homegrown religion (eg. The Church of Jesus Christ of Latter Day Saints, Scientology, etc…) is ongoing with a vast proliferation of organized church groups embracing sacramental use of psilocybin containing mushrooms and a wide array of plant medicines. How the winds of political change will blow and what will ultimately determine the legitimacy and protected status of these organized churches, is anybody’s guess. Suffice it to say that many people find a sense of belonging in spiritual communities that seems ever more challenging to hold onto in our modern world.

It’s early days for our society to reconcile and legitimize the use of psychedelic medicines. Across the country, local initiatives have decriminalized possession of some plant based psychedelic medicines for personal use severely deemphasizing historical enforcement efforts. Eureka and Arcata, California are just two examples of successful local action; a number of communities have failed with similar initiatives. Though statewide legislation decriminalizing psychedelic medicine and creating a regulated delivery system have passed in Oregon and Colorado, efforts to pass related legislation have failed in Massachusetts and California. As the data from these social experiments mature, we can expect to see more legislative efforts at the local and state level, with some expected movement at the federal level where these substances remain illegal outside of clinical trials, FDA approved drugs (eg. Spravato, racemic ketamine off label), or in religious context. Shifts and changes seem to occur on a weekly basis with no clear clues about what to expect around the corner.

There is an important and decidedly concerning element to the impact of these extraordinary states of consciousness that needs to be understood. While they may be a source of human strength, access to wisdom, and a pathway to personal and community healing, they are not a panacea. In fact, the human desire to gather power over others and our almost infinite capacity to delude ourselves can and does complicate the impact of these medicines. All too often, we can, and do, inflate our sense of our own value and importance. We can, and do, exaggerate our talents and abilities with arrogance and hubris; when we would be most useful to others by focusing our attention on a rigorous assessment of our limitations, we can, and do overreach causing harm. Some of us take this inflated egoism and elaborate this into a domination and exploitation of others for personal gain with narcissistic zeal. Without self awareness or or capacity for anything resembling compassion for others, these individuals exploit others for sexual and financial gain with cultish tricks that have worked on their fellow human beings from time immemorial. Sadly, this incredibly dangerous human phenomenon affects doctors, therapists, shamans, priests, healers, leaders as well as housewives, policemen, and refrigerator repairmen equally. Many with power seek to gain more. Those without power are vulnerable to the seduction of those that seemingly have gathered it. Unfortunately, in addition to the healing potential and deep value that psychedelic medicines offer to us, they also make this effect of ego inflation and narcissism more dangerous.

In the global north, we have embraced a material and mechanical mindset centered around our physical safety, accumulated experiences, longevity, and acquisitions. It is a black and white mindset, starkly contrasting right and wrong, good and bad, health and pathology. We have been somewhat blind to non-physical aspects of well being. Our limited success in responding to the rising storm of mental health and suffering is contrasted starkly with the power of technology and failing social structures to generate such misery. We have developed our vast armamentarium of tools to repair and address only what we have determined and defined as pathological while missing the many subtle and not so subtle challenges we face in the deepest psychological and spiritual dimensions. In search of the next great technology or cure, we demonstrate a form of magical thinking that allows us to support a delusion that we understand the mysteries of ourselves and each other. We don’t, and the pretense and hubris of this narrow and monocular view can’t see, and certainly can’t offer healing to so many of us that suffer physically, psychologically, relationally, and spiritually. We are so much more than the sum of our physical parts. The extraordinary and improbable existence we share with all living beings cannot be understood through reductionism and science alone if such inquiry is polluted by righteousness and dismissal of the vastness of what we don’t even know we don’t know.

The rate of change and destruction resulting from human activity continues to accelerate. The society we have built is failing to meet the needs of its members. Perhaps, we should not be looking outside that system. Not for the next cure or Magic Pill to solve, fix, and repair our hearts and minds and spirits. Together, we might look towards the vastness of what we don’t know that we don’t know. With humility and compassion, towards completely different models of understanding what it means to live and heal and thrive. This complex and rising interest in psychedelic medicine work may lead us to new ways of understanding, if we can handle passing through such a gateway. In the words of poet Adrienne Rich noted, “The door itself makes no promises. It is only a door.”