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How should the living think about death?
It’s a question humans have grappled with since the beginning of time. Ancient Egyptians built the pyramids and created the Book of the Dead to guide souls through the afterlife. Buddhism set as its goal an escape from the cycle of death and life through enlightenment. Then in the 20th century, German philosopher Martin Heidegger argued that truly living requires confronting your mortality. And French philosopher and author Albert Camus found that death made life absurd, but argued that this is what gives it meaning.
Now, a new narrative medicine project in rural northern California aims to explore the question of how to face death through a set of films about psychedelic care for people with terminal illness. The Institute for Rural Psychedelic Care in Arcata, California, which has been using ketamine with palliative care patients for almost four years, is developing the films, which will feature interviews with patients on four themes: unfinished business and regrets; quality of relationships and love; legacy and meaning making; and finally, what exists beyond death. These are themes they say come up over and over again in their work.
“How do we engage in longer-term storytelling around these liminal experiences?” asked Carrie Griffin, a trauma therapist and psychedelic medicine practitioner who is working on the project. Through storytelling, they want to not only engage broader audiences in questions about end of life, but help clinicians learn to more fully engage with their patients, and ease anxiety in the terminally ill. Griffin is working on the project with rural palliative care physician Michael Fratkin and photographer Justin Maxon, who recently won a Guggenheim for his work documenting the opioid crisis in the Hoopa Valley, in California.
I spoke with Griffin about what makes psychedelics well suited to end-of-life care in rural settings, the human need for meaning, and the aims of the project.
What about psychedelics makes them so appropriate for end-of-life treatment?
I’m trained as a physician, so I’ll start with the physiology: One thing that psychedelics do is they increase something called brain derived neurotrophic factor, or BDNF, the molecule of neuroplasticity. When people talk about how exercise is so good for you, why sex is so good for you, how do we grow new parts of our brains? BDNF is the molecule that helps that to happen. So you’re taking in a substance that’s clearly creating a state change.
Ketamine in particular increases glutamate. Glutamate is the most abundant neurotransmitter in the cerebrospinal fluid. It’s an excitatory neurotransmitter. So when the neurons release glutamate through these vesicles, glutamate floods the brain, and it causes a downstream effect of serotonin and norepinephrine and other neurotransmitters to be released. And there’s something about our perception, our consciousness, that’s connected to these floods of neurotransmitters. But of course, this is a very mechanistic model of what it means to be alive. It lacks soul, right? It lacks a sense of deep mystery.
You want these films to communicate that mystery?
Yes. There are all these things about living and dying that are difficult to codify in language or in knowledge. We want these films to help bring some of that mystery to life. The idea is that the films could be used to support anybody’s reckoning with their own mortality. On one level, this will happen to you regardless of whether you reflect on it or not. But for those of us who have been working in medical liminal spaces, so birth and death, we’ve found it makes a really big difference if people have taken some time to reflect and slow down and notice, “What’s my body’s relationship to the fact that I’m going to die? Am I gonna be scared? Is it gonna hurt? Where do I go?”
Those are big questions. Do they have answers?
There’s a lot to reflect on. We don’t need to spend all of our days being contemplators, meditating on graveyards, but doing some of this is a powerful spiritual practice. It’s good fodder for awakening. And I actually think that’s part of what we’re here to do: to help wake us up. We also want people to see how your whole life is art. This whole thing we’re doing on Earth is a creative act. The more we can remember that the more we’re able to connect to this profound sense of agency that it’s very easy to forget.
People want to think and feel deeply. People are hungry for something that actually has substance to it. We don’t just want 32-second videos. These do something, but eventually these little nothing bites just lead us to downloading the gambling app. We’re designed for depth. We’re designed for a different tempo.
Is there an ideal time to give psychedelics to the dying?
It’s super individual, but there’s a general opening of opportunity if, or when, someone is having discussions with hospice. The general thought is that you have a six-month or less life expectancy, so that’s a really potent window.
Read more: “How To Tell If You’re Dead”
How do you decide whether psychedelics are the right approach for someone?
I mean, psychedelics are very alluring. They’ve been alluring for millennia, but they’re definitely having another moment, another season of being hot and being sexy and being interesting. I feel like whenever I see that, my immediate instinct is to harmonize the narrative and say they’re not for everyone. There’s lots of ways to create a change in consciousness. That may be through breathwork or meditation or close reading and close writing, deep reflective practices. It could be through movement. There are lots of ways to create state changes within ourselves.
But one of the first people we recruited for this project has a form of ALS [a fatal neurodegenerative disease, also known as Lou Gehrig’s disease] and he communicates with a speechpad and watch. And he’s had, I think, four treatments at this point with ketamine. He even did a session with his family members, too. They all got medically cleared and all went through their own individual therapy process, and then a group preparation process, before experiencing it together. Of course, if someone can’t consent to that kind of care, you don’t proceed with that kind of care.
Are psychedelic drugs best suited to certain kinds of terminal illness?
I will say that for people who have a neurodegenerative diagnosis like ALS or Parkinson’s, you know that the body is going to fail you. It’s progressive. That’s a little bit different than someone with chronic kidney disease where we could maintain them on dialysis until they stop. Or even someone with chronic obstructive pulmonary disease, where eventually they reach a point where they’re requiring oxygen, but not getting relief. There’s that chronic air hunger. But there’s a slow, yet sure progress in neurodegenerative conditions that does feel unique. And the other group, of course, is cancer. So people who have cancer that has metastasized to stage three, stage four, perhaps they’re choosing to use their ketamine-assisted process to determine if they want to continue with some kinds of chemotherapy or radiation.
How do you measure success in psychedelic end-of-life care?
One way to support a person’s reckoning with a chronic disease process can be to help them reflect on the day-to-day quality of their lives. What are they missing? What are they longing for? What have they minimized to the point that they don’t even realize that they’re missing it?
Then, of course, there are psychological scales that have been confirmed and been validated. There’s an end-of-life anxiety scale. There are a number of regular behavioral health, mental health scales, like the PHQ-9 for depression, or the GAD-7 for anxiety. There’s a quality of life at end-of-life scale.
What made the three rural counties you’re focusing on an especially good fit for this work?
Well, one, bloom where you’re planted. We’re here in a very interesting geographic area. We’re in what’s called the Redwood Curtain, all the way up in the far, far north. It’s hard to get here, and it feels a little bit like living on an island to me sometimes. There’s really a quality of untouched raw earth here. This is where the highest predominance of Redwoods are, the Redwood National Forest. This is where Return of the Jedi was filmed, the Ewok Forest. There’s a kind of primeval quality to the land here.
Do rural patients face different end-of-life challenges from urban patients that psychedelics can uniquely address?
One of the things that I think is very true about psychedelic medicine in psychedelic practice is that it happens in community. When you look at how all kinds of Indigenous substance work was done, when you look at how ceremony is practiced, it’s in community. You have lots of practitioners around you. It’s a very collaborative model of care, it’s a slow, deep, rich experience. You can’t make it faster. And I’m sure there’s an army of tech bros who would hunt me down and tell me this is not true, but I actually don’t think psychedelics scale. Because to do them well, to do them with intention, it’s slow and it’s deep and it’s held by many people.
That’s why we’re taking this clinical-meets-psychological-meets-spiritual experience and embodying it through short films and then inviting deeper reflection and engagement. We really want to foster conversation and community around this experience that all of us are going to have. Loved ones die. Pets die. The plant next to me will die. We all die. 
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Lead image: fran_kie / Shutterstock
