What Dying Can Teach You About Living with Dr. BJ Miller

Palliative care physician Dr. BJ Miller survived a near-death experience and lost three limbs at just 19 years old. In this intimate conversation, he tells Sarah how confronting mortality reshaped his purpose, and opened his heart to awe, humor, creativity, and love. BJ has been on a mission to redefine end-of-life care through his work at Mettle Health and his book, "A Beginner's Guide to the End." He invites you to challenge the fear and silence around death, and imagine a better way to live — and die.

Transcript:

Sarah: Hey, it's Sarah. We wanted to let you know that today's episode of Peaceful Exit contains a discussion of death by suicide. If you or a loved one is struggling or in crisis, please seek help. Free and confidential support is available 24/7. Just dial or text 9 8 8 to connect with the Suicide and Crisis Lifeline, or visit 988lifeline.org. You don't have to go through this alone. Okay. Here's the episode.

BJ: The mind bender of knowing we die before we die, as is the human experience, is sort of the riddle of all riddles and has been the sort of subject of most or all religions. How do you love life even while you're losing it? This is ancient stuff. It's neurological stuff. Humans have struggled in this way forever.

Sarah: Welcome to Peaceful Exit, the podcast where we talk to creatives about death, dying, grief, and also life. I'm Sarah Cavanaugh, and my guest today is Dr. BJ Miller. BJ is a palliative care physician and author who's transforming the conversation around death and dying. He's best known for his TED Talk, “What Really Matters at the End of Life,” and his book, “A Beginner's Guide to the End,” which he co-authored with Shoshana Berger. BJ invites us to see death not as a medical failure, but as a shared human experience worthy of grace, care, and creativity. BJ also shares why he recently decided to step outside the traditional healthcare system to start his new company, Mettle Health.

Welcome to Peaceful Exit. I know your book came out six years ago, but I really enjoyed it and your story, I know it went viral on a TED Talk. Please share your story of losing your limbs and how it propelled you into the work you do now, or as you say, it kind of woke you up.

BJ: Well, happy to, and thank you for having me, Sarah. It's nice to be here. Yeah, so when I was sophomore year of college, I was 19 and this is about 35 years ago, coming up on 36 years ago. Friends and I were just out on a Monday night. We weren't going crazy, but we were out screwing around and we were walking across campus on our way to get a sandwich at what's called a Wawa market on the — in the northeast, like a 7-11 or a convenience store open late. So anyway, we were walking to the Wawa to get a sandwich or whatever. And on this campus, this was at Princeton University, and there's a little commuter train that runs up right onto the edge of campus. Princeton's sort of a bedroom community for Philadelphia and New York. So it's a simple commuter train with the wires that run overhead. It wasn't moving, it was, you know, after hours just sitting there and there's a ladder on the back and we just climbed up on top of the train like you, like you would a tree or something. It wasn't train surfing. It wasn't, we didn't think we were doing anything crazy. Anyway, when I, I stood up, I had a metal watch on my left wrist and I got close enough to the power source that the electricity arced to the watch, and that was that. So, then whisked off to a burn unit in Livingston, New Jersey for several months, and ultimately survived obviously, but three of my limbs did not. So I lost that left arm below the elbow and both legs below the knees as a result. So that's sort of the gist of what happened per se. But the fun stuff, of course, was what the heck to do with that experience when you're 19 years old and in so many ways nothing changed. One of the things that was so fascinating to be in those shoes and experiencing all was like, yes, I did come close to death and for the first four or five weeks, the idea that I could die was never far away. So it was very touch and go for a long time. What was interesting was how little changed in my inner dialogue, in my inner life. There was pain and there was fear of a certain kind, but one lesson that quickly emerged was like dying and living look a lot alike. And so it was this very profound experience and also a very mundane experience. And that's held true as I've spent a lot of time at Deathbeds over the years. It's a little bit of both, but yeah, I had a big old confrontation with my mortality and it really shook me in a lot of ways and helped me get clear on the poignancy of life and how we're not here forever. Something you and I know of course, but to really understand that in your bones is something different. And so I just got to watch how coming close to death really changed how I lived my life. And so that's why I went into medicine and pursued my life as a physician so that I could be with other people who were in that zone.

Sarah: Say more about how death and life look alike to you.

BJ: For one, it's just, you know, dying people are still alive. Who isn't dying? Like when do you start dying? Is this a reminder to us all that dying people are still living so that we don't accidentally sequester them or think of them as so different from ourselves. Because so much of the trouble comes from that misread. So, yeah, I mean I think it's a very fair question to ask any of us. Like when do you start dying? I think at birth might be a very reasonable answer.

Sarah: Absolutely at birth. So my mother-in-law is a double amputee. She has been for over a decade. I adore her, but I've gained so much understanding and admiration for her determination. I've learned a lot about what it's like to live in a wheelchair and how challenging it is. Were there any particular people in your recovery that really stood out as caregivers? Because I'm sure there were some pretty hard times as you're recovering from that accident.

BJ: Early on, I was very close to some nurses. As happens, you know, you live in a burn unit for months. It's a really odd environment and what I imagine a, a war zone might feel like. It's hard, it's painful, it's many things, and all of that difficulty draws you closer to the people around you who are sharing that space with you. There was a nurse named Joy. There was a nurse named Darlene. My college buddies were hugely helpful, my parents, and at that time my sister was alive and she too was very helpful. A particularly important relationship was with my mother and my mom had polio as an infant and post-polio syndrome and has used a wheelchair much of my life. She initiated me in the world of disability. So that relationship was super poignant for me and perhaps extra so because of this shared experience as a disabled person,

Sarah: I would imagine so that's really incredible actually, that you had her as a model.

BJ: Yeah, it was very helpful, incredibly helpful. I knew right out of the chutes that I didn't make me less human, that I belonged (Sarah: Exactly) and that I had grown up with a sort of civil right notion of disability rights. That was very empowering and it helped me not hate my own life or hate myself more than I needed to for a while.

Sarah: Is she still living?

BJ: Yeah, she is. She's 82. Post-polio continues to have its way with her and she's hanging in there and puts up with all sorts of stuff, it continues to amaze me.

Sarah: Same goes for my mother-in-law. (BJ: Yeah) She's quite amazing and she's refusing help even at age 80, almost 89 next week. (BJ: Wow) And she's still, oh, she still won't accept care. What did your mom teach you about death as a child? Did your parents talk about it?

BJ: Not really. Not much. They still don't much, actually, they're both in their early eighties and despite my line of work, they like what I do and respect it, but it's not like they take all my advice here. They're of a certain ilk where they would consider a lot of what I do to be naval gazey. In some ways it is, you know, I like just contemplating. There was not much conversation around death and mortality per se, nor was there an allergy. So it wasn't like a house where you couldn't say the D-word or something. We just didn't have, there was no family relationship to it. You know, I remember my grandmother, my dad's mom died when I was seven or eight, relatively young in life. Being with her at the end, seeing her in the casket was revelatory for me at a young age, but there wasn't a lot of family processing it. We didn't talk about it much.

Sarah: So you wrote that after your accident, you needed people to see that you were not afraid and so, sort of fake it till you make it. Does that mentality work?

BJ: For a time. What it did was, in retrospect, it was, it's like a very, it's like maybe guilt or shame. I did fling myself back into the sort of socialized world. Got back on the horse of college as quickly as I could. I didn't wanna lose time. I knew the emotional and psychological fallout was gonna take a long time to work through. And what I really did was I, I made some choices. Like my choice was to physically put myself back on the horse, back into school, back into that context. And that required me squinting my way and partially addressing things that were coming up just to get through the day, just to mechanically move through school. And it was a trade off. I knew that there would be something good that would happen by being with my peers again and my classmates and that would motivate me in a way, and help me get up off the couch. Because I could feel like an abyss, like if you wanna opt out of daily life, there are lots of ways you can, and it's very seductive. This is also maybe thanks to my mom, I knew to not take this sort of “you’re special now” bait because that's just another way of separating you out. So I knew to not take that bait, so I was just wheeling myself back into the world in a way that meant I was incompletely looking at the whole picture. But over time, I got there, and in retrospect, I'm glad that the path that I took, but it certainly wouldn't be for everybody.

Sarah: I do love when you talk about wearing extra short shorts, being around my mother-in-law, knowing that she often covers herself so that other people aren't uncomfortable. But it makes complete sense now that you say your mother really showed you that it's okay. And when you wrote about I just needed my skin to be in the air, um, and I imagined you on campus, so I really just appreciated that moment in your story.

BJ: Part of it was just I needed to feel my own flesh in the air in the world. I look at my body and I’m a, you know, part machine. So part of it was just this aesthetic experience. And another part of it was this identity kind of forcing myself to, okay, people are gonna be staring at me one way or another. (Sarah: Yeah, either way.) I need to find — either way — so I need to find a way to either challenge that or play with it, or just not be prisoner of it, which can happen.

Sarah: How soon after your accident did you recognize you wanted to work with patients at the end of their lives?

BJ: It really was, it took a minute. All through medical school I thought I would go into rehab medicine and just because the impulse was to work with other people who had an injury or something gone wrong and they were in some recovery mode, and I figured, oh, those are my people. And it wasn't until late in med school that I realized I didn't really like the practice of rehab medicine, That I was really less interested in the mechanics of recovery and the physiology of recovery and I was much more interested in the sort of spiritual and maybe philosophical, like: what makes a human being a human being and what do humans do when they bump up against the limits of what they can control? That is the interface that was really, it turned out to be most interesting to me, and so I was gonna get outta medicine altogether. Because I had promised myself I wouldn't do this as a sort of a sacrificial pursuit, having come close to death I knew better than to do that. But anyway, my dean talked me into doing my internship the first postgraduate year, and my parents were in Milwaukee at the time. I went back and lived with them and did that internship and then stumbled on, I did an elective in palliative care. I don't know if I'd ever even heard of it. And I stumbled into it as an elective and fell immediately in love with it. And here was a field that was devoted to subjectivity, the subjective experience that people have. The rest of medicine, always kind of trying to objectify you for good reason, but they're also trying to always fix you. And sometimes you're not fixable. When you're not fixable and everyone's trying to fix you, it's not a great vibe. And so here was this field palliative care that was new-ish. That celebrated the subjective experience, loved you, whether or not you were fixable, and that was really key. When I jumped into palliative care, it was for those reasons, at least consciously it wasn't about mortality, it was really more about suffering and disability and like I say, bumping up against things you can't control. I realized that that was sort of the mother that was the root of so much of human experience, of our fears, et cetera. And probably why disability remains terrifying for people. 'cause it is another step towards death or it's a partial death. So during my fellowship in hospice and palliative medicine is when I found myself more and more interested in the mortality piece.

Sarah: Have you ever met Sheldon Solomon? He's a professor who wrote the book, the Worm at the Core,

BJ: No.

Sarah: And he'd, he studied the fear of death. For, I don't know, 30, 40 years. He's now 70.

BJ: Yes, I do know this man. Yes. I don't know him, but you know of his work.

Sarah: Yeah. Yeah. I had a conversation with him and it's so interesting how they were studying really that fear of death and that awareness of our mortality is really at the core of all of our ills.

BJ: Yes. This is terror management theory.

Sarah: It was really fascinating to talk to him that he had just turned 70 when I was speaking to him, and as is often happens, he said something around that, ‘I'm 70 now and I realize I've been studying this for 40 years, but I haven't done it for myself, that it's now time for me to face my own fears.’ It's really true of all of us. We hit a certain time, and whether it be an accident in your case or hitting a certain age, something that trips you up.

BJ: We are wired to run away from any threat to our existence. We have these fight, flight, freeze reflexes, and the mind bender of knowing we die before we die as is the human experience, is sort of the riddle of all riddles and has been the sort of subject of most or all religions. How do you love life even while you're losing it? This is ancient stuff. It's neurological stuff. Humans have struggled in this way forever. If anybody, if they have any kind of fear of death, et cetera, it is, it seems to be pretty darn natural. When I'm actually at the edge of my horizon and actually going, I reserve the right to freak out.

Sarah: Let's quickly clarify for me the difference between palliative care and hospice care. You call it the dynamic duo in your book.

BJ: It's just since 2006 that this was named a specialty, and the specialty is called Hospice and Palliative Medicine, implying that the two things are related, but a little bit different, and it's true enough. But it's probably easier to think of hospice and more sort of concentric circles. Hospice is a type of palliative care that is reserved for the final months of life, and it's a bullseye of this work. Hospice, as a notion's been around for millennia, a place for the wretched, you know, the language you'll read in history books and stuff. And then in the 1960s, Dame Sicily Saunders in the UK founded this sort of modern hospice movement, this new sort of medical specialty, and she defined it as inherently interdisciplinary. Doctors, nurses, social workers, chaplains, volunteers, art therapists, et cetera, because the subject's much too big. By the time hospice as a notion landed in the US it was a kind of a counter-cultural social model. American healthcare wasn't ready to receive it per se. Then in the 80s, Medicare got in the business and named the hospice Medicare benefit. That was a big moment, so it concretized this care and made it much more accessible for people by systematizing it and making it an actual insurance benefit that we were guaranteed. Congress decided they needed to put some limits on it to pay for this kind of care. They said, to qualify for hospice now that it was an insurance designation, you had to have six months or less to live, and you had to give up curative intended care. It sort of unfortunately plays into the narrative of dying as giving up. And so to get around the insurance benefit and its limitations, the field of palliative care was born. And that phrase came to us from a Canadian surgeon, Balfour Mount, who recently died. He was a giant in the field. He came up with that phrase to get around the rhetorical baggage of hospice. Hospice really started us off, and palliative care is its sort of younger but bigger brother or sister. Palliative care is simply, in the biggest sense, is simply defined as interdisciplinary care for the pursuit of quality of life and the mitigation of suffering. You can get palliative care years before you die. It's not tethered to the clock in that way, and it's wired to not force you to give up anything. And then hospice is a subset. It's the same team, doctor, nurse, social worker, chaplain, same training, but it's sanctioned through this benefit and reserve for those final months of life. It is more time limited.

Sarah: People think of hospice as kind of a death sentence almost. People resist it, so I understand. Again, we're back to languaging something that most of us will need in our lifetime, and a lot of people wait too long to get that support.

BJ: People wait so long because of the baggage. It's gotten better, but the median length of stay in the hospice is pretty short and a lot of people are only in it for a few hours or or days. (Sarah: Right) Because they just wait until the very bitter end when they would receive any sort of acknowledgement of care.

Sarah: I do think one of the most beautiful things about hospice and palliative care is it gives support to their caregivers as well. (BJ: Exactly) You know? And if not for yourself, do it for the people that love you. Well, your book, “A Beginner's Guide to the End,” is evergreen. So chapter one, you start out, don't leave a mess. And why do you start with that instruction? Because I do think that is literal and relational and spiritual, all in, you know, meaning a messy life.

BJ: We started there because I think we've learned that you need an on-ramp to the subject that is a little less charged for people oftentimes. So a practical or almost clerical way into the subject is maybe boring but a little less scary for people. And I think we also wanted to get out of the gates here that again, this notion that we affect each other and how we die is often how we live and vice versa. If you can't find your way to caring about yourself in a certain way, for your own sake, maybe the fact that it'll affect your children or the people you love can be a little bit more motivating for you.

Sarah: I love that interpretation. As we talk about in Peaceful Exit really, it's about when you are of sound mind and body, that it's important to have these conversations and to look to what is left behind. We used to talk about it in business, like if the founders of this company are hit by a bus, what's gonna happen to the company? But for your life, if you were suddenly not here, what would be the impact on the people that you love?

BJ: It's amazing how much we affect each other even beyond the grave, and we can extend our care and our love for each other in all sorts of ways, including through how we die. And so I don't want people to feel like they're held hostage, guilted into doing anything, well, because it'll make my daughter's life easier. Well, I guess I have to do blah, blah, blah. But I think it's also really important to keep an eye on here for why this is just so magical. We can do things now that help other people hurt less. And that's, that, there's a spiritual pursuit right there. So even as you're handling your stuff, it can be through this sort of magical interdependence that just working from this place where we know we are affected and affect each other, that the world is different with us in it. And what we do matters.

Sarah: I love that. I was talking to a friend a couple days ago and she was telling me about her grandmother, who would put sticky notes under things. So someone would say, you know, I love this teacup. She'd grab a little piece of tape or then put their name on it. And so this, this was happening for years and so by the time she died. There was sticky notes everywhere. She still enjoyed those items, but she gifted them before, well before she left.

BJ: Beautiful. I've heard a lot of stories like that. I wonder if for her, you know, when she would look at those objects and use them and see those sticky notes, I would imagine that enriched her own experience, knowing that she was gonna stay connected to these people even after she was gone.

Sarah: Absolutely. She even shared that on her 90th birthday, all the grandchildren got together and did a skit about the sticky notes where they were like, they were trading, and so she actually got to see them enjoy the process of what she was offering. (BJ: Beautiful) So it was, yeah, it was a beautiful story. So you've written that the final stretch of life can be stunningly beautiful, and you've spoken about the value of sensuous, aesthetic gratification. What does that mean exactly?

BJ: So there's a couple ways in this subject and one is just like watching yourself, watching myself move through the day, especially as I came out of my injuries and my body had been a source of pain in so many ways. I am alive, not just 'cause I have a pulse, but because I feel alive. There's a big difference and what does that entail? It often, or maybe always, includes something that's mediated through our sensory experience. When I would talk to clients or patients and family members, you start noticing like, very often a memory will include a person that is close to them, but the memory will be something like, having ice cream on the 4th of July parade, or this meal I had with so and so. They're almost always talking about an aesthetic experience, often with someone that they really cared about. But the memory is enveloped in this sensuous experience, and I mean sensuous, not necessarily sexualized, I mean literally of the senses. I hear so many people talk about, well. You know, get me off the planet as soon as I don't recognize you. Or oftentimes their identity will be so wrapped up in their intellect or their cognitive capacity, their ability to think and communicate and hey, that's powerful stuff. I don't, yeah, I get, I I get that. Yes. And if someone had asked me, ‘Hey man, you think you could lead a good life if I lopped three limbs off?’ I'd probably be like, ‘No. You know, I don't. No’. But since it happened, I got to see something evinced in me that I didn't even know was there until it happened. And I see folks who have dementia and other cognitive issues who can still feel things.

Sarah: What have your senses, your sensory experiences, what have they meant to you as someone who's lost some?

BJ: Well, having lost some helps me remember how precious it is. I mean, it's a just a wild phenomenon to be alive. It's just outrageously unlikely. Just the idea that you and I are sitting here sharing time and space together on the same planet at the same time, and the same galaxy. It's just, it's crazy. It's wild.

Sarah: Statistics are like —

BJ: It is just nuts. (Sarah: Impossible) Exactly, and yet here we are. That kind of perspective making that can come from losing something and forced to grieve it and forced to pay attention in a different way. My goal in life is really to appreciate all that I have while I have it. It's very easy to appreciate something after you lose it.

Sarah: I'd also imagine it like expands your humor. My mother-in-law makes a joke about we only need to buy a child's coffin because without legs she's very short.

BJ: Exactly, exactly. It is. It's absurd that we're alive. It's so odd and so yes, it should be — so humor should be really accessible and sacred too. You know, not profane, necessarily. Laughing at our experience is really, really key. I've gotta learn to love this thing and lose it at the same time? Ouch.

Sarah: We talk a lot about how we internalize. And tell ourselves about death on Peaceful Exit. You've been quoted as saying, ‘Let death be what takes us, not lack of imagination.’ I'm curious what you see as the role of creativity and imagination in this work.

BJ: I think we're all way more creative than we give ourselves Credit for. Daily life is filled with improvisation and navigating reality as it's unfolding, and also coming to realize your role in creating reality. It's not just this received thing, it's this yarn that's continuously spinning and you're involved spinning it. And you watch the stories that we tell ourselves and each other, how we make sense of our lives. Those are all creative acts. Most of us don't give ourselves the moniker of I am a creative or I am an artist. I shy away from saying that too, but I actually believe that to be alive is to be creative.

Sarah: So how do we change the story around death in this culture?

BJ: You and I are both trying to do that one way and another. Pointing to the lessons one can learn and the enrichment that can happen when you wrestle with your mortality is one answer to your question. I think another is, so we're all very aware of the divisions in this country right now. Very powerful and very sad. Isn't it particularly helpful then to note what we have in common as a way to get reconnected or maybe say, rediscover the fact that we are connected. It's like I feel closer to you, Sarah, just by acknowledging that, oh my God, you and I, two people talking at the same time, the same place, exchanging with each other. Isn't that wild? So I think that's part of the answer to your question. I would love to see this country really collectively put some effort into grieving because you and I know that grieving’s not fun, but it's a natural phenomenon that helps you understand what you love, helps you honor what you've lost, and helps you pay attention to what you still have. So I'd love to see grief done proudly and, and, and big in this country. I think it'd be very helpful.

Sarah: Let's talk a minute about grief, because I recall you were laughing as your sister's casket was lowered into the ground. Did that kind of grief catch you by surprise?

BJ: Yes, very much. Oh, I was so, I was aghast at myself. I couldn't, and it sounded like laughter. I couldn't, it was like a weird cackle. It was like a sort of a strange, I couldn't control it, and I certainly didn't think it was funny, but maybe there was a note of the absurdity. You know that we were referencing earlier. But some, some amalgam of experiences in me just — that's what popped outta my face, was this weird kind of cackle. And I remember being completely surprised and really ashamed. This was solemn. This is not funny. It was very odd. I now have much more sympathy or empathy for myself or something like that, let’s say compassion for myself. I was like shortcircuiting. Here I am with this proof, watching my sister go into the ground, and it just didn't compute in some way. And there was a, my realities, my inner reality and the outer one were colliding in such a way, and I had to offgas in some way, and I out came a cackle. But back to your question. Yeah, no, I, that did surprise me. I since now understand it more.

Sarah: I resonated with it because my father-in-law, as he was being lowered in one person, let go of the side. So the casket like tipped and everyone just sort of, you know, everyone had their own sort of reaction to it in the moment. How has losing a sibling changed your perspective?

BJ: In some ways, not at all. In some ways, a lot. It's weird that I decided to pursue hospice and palliative medicine the year after my sister's suicide. I didn't deal with my grief with Lisa's death for many years, and so it's maybe not so surprising that it wasn't part of my narrative. I just sort of put it in a black box and pretended like that was, you know, kind of pick yourself up kind of mentality, which I bought into. That you could somehow sidestep grief with enough willpower or something like that. I, I come to realize that that is just that you don't ever sidestep grief. It will come around. It’ll have its way with you one way or another. In retrospect, I wish I had really just embraced my grief right out of the chutes, in part because that would allow me to embrace my sister, that would allow me to have a relationship with Lisa ongoing. But by cutting myself off from consciously grieving her, I cut myself off feeling connected to her until many years later. You know, in some ways I'm still learning what Lisa's death primed in me. My sense is that as I keep going here and more and more of my subconscious or unconscious becomes lit, that I will see more and more ways that Lisa's death has affected me. I'm still waking up 25 years later to all that her death signified or meant. I know she suffered mightily. I don't think that Lisa's death is my fault, but I can't help but wonder if I were clearer on the worldview you and I have been sharing today that normalizes suffering, that doesn't shame someone for not fitting in to these narrow structures we create for each other and ourselves. You know, if I had been a little bit more apt to accept her and all of her pain, and I had participated in a world that could hold someone's suffering a little bit better without shaming them, then I think she might still be alive. Something in me believes that. I don't of course know that that's true, but I do feel that the world that I'm working towards helping to create where we're not ashamed to be real essentially, and reality includes death. Therefore, I care about it. That my sister's experience would've been importantly different. I guess I do believe that

Sarah: Are you her? Older brother?

BJ: Younger,

Sarah: Younger brother? Yeah.

BJ: She was three and a half years older.

Sarah: I was wondering about that, like subconsciously if you went into palliative care thinking, you know, if, if you could have helped somehow.

BJ: Yeah, it seems impossible somewhere in me that wasn't happening, but it was nowhere near my conscious narrative still isn't.

Sarah: I love the word mettle, the exact word that speaks to determination and the grit it takes to live while you're dying, which we all are doing. Talk for a minute about your decision to start Mettle Health and what wasn't happening in your clinical practice that you thought you could do better with this.

BJ: The writ of hospice and palliative medicine — again, this interdisciplinary pursuit of quality of life and the mitigation of suffering or something like that. I mean, there's no bigger banner under which to operate. And then you take that great big mandate and then you ram that into the structures of healthcare and you can quickly see why it, it seems maybe impossible to realize the full potential of this mandate within the structures of healthcare. So after working in those trenches for many years, and I loved it in a lot of ways, but this 15 minute clinical encounter is absurd. If, if you're trying to do this work in its fullest expression, it's impossible. So after many years of trying my best to ram all that bigness into this very hyper reduced model, it just became demoralizing and unnecessarily problematic. I say unnecessarily because these systems are inventions. It's not like Mother Nature created healthcare. You know, you referenced earlier, let death be what takes us, not lack of imagination. Like we just need to imagine better systems. Nursing homes post-acute care, the structural elements around end of life are so lame, but they're made up, they're invented. So we can make something else up. That's where I wanted to keep engaged in the imagination. I did my best for as long as I could in that system, and that's where people are. You know, I love that system too. It saved my life. There's a lot of good that happens there too, but there's a lot that's impossible there. So with that impossibility in my mind, Sonya, my business partner and I stepped out of healthcare early in the pandemic to create Mettle Health as a non-medical place, to let go of the prescription pad, but then to open up more time to have conversations like ours, Sarah. Like to get really deep into it with people, into bigger truths than just whether or not they have nausea or getting to the next chemo appointment. So that's why I stepped out of the system.

Sarah: Well, what does a peaceful exit mean to you?

BJ: I think it is one where we don't need to reconcile paradox, where we can have simultaneously conflicting emotions. And we can be all that we actually are without being ashamed. The fact that we create structures that make you feel like you don't belong is really important. So these sort of manmade sources of pain and suffering are the ones I'm interested in changing. That's the activism, that is the part of this experience I actively want to change. So back to your question about what a peaceful exit would be to me, one would be where I can be butt naked and throwing up and smell weird, and be maybe even terrified and screaming, but be whole doing it. Be not at odds with myself doing whatever I gotta do. So it may not look peaceful in the typical way, but that's the kind of piece I'm seeking.

Sarah: Complete authenticity just where you are in your body or out of your body.

BJ: Yes. Period. Exactly right. Yes. All of the above.

Sarah: All of the above.

BJ: Yeah.

Sarah:  Thank you for listening to Peaceful Exit. I'm your host, Sarah Cavanaugh. You can find us on Instagram at A Peaceful Exit and on YouTube at Peaceful Exit Podcast. To learn more about this podcast and my work, please visit peacefulexit.net. You can also send us an email and let us know what you thought of this episode, or share an idea for a new episode. We're at peacefulexitpodcast@gmail.com. Our senior producer is Julie Kanfer, and our sound engineer is Jason Gambrell. Additional support from Cindy Gal and Ciara Austin. I have an amazing team. Original music provided by Ricardo Russell. Please make sure to follow us on YouTube, Spotify, or Apple Podcasts, and rate and review us wherever you listen. It really makes a difference. And please tell your friends about Peaceful Exit. As always, thank you for listening.