From earliest times, sages have advised us to become comfortable with transience, more than that, to be at peace with our approaching death and to keep it in constant view. Whatever the benefits of such a perspective, they must surely be harvested in abundance by those working in Palliative Care! An ongoing personal cost/benefit analysis of our daily confrontation with death is for many a legacy of the trade. “Why” questions are our persistent companions. They have colored my recent days as I holiday with my family in a cottage on Lac Massawippi in Quebec.

Stop time! I just heard the news. Phil died a few hours ago. It was expected, really.

Responding to his questions, I had told myself, told Phil, and those who love him, what to expect, how it would be. I tried to accompany them, suggested how best to manage his unresolved symptoms and how to support loved ones exhausted by the struggle involved in pushing water up hill for too long, while “learning to fall” (Simmons, 2002).

Dead? Yes, Phil's death was expected. But thinking about death and actually experiencing its finality are two different things. Suddenly I have feelings that are unexpected—waves of sorrow too deep to express; waves of pleasure that engulf the flood plains of memory. Memories of Phil. I oscillate between grief and joy, born in the simultaneous experience of both loss and potential that accompanies all endings and the beginnings that they thrust upon us. I struggle to integrate the new realities inherent in a Phil-less world.

Philip Simmons was 45. A.L.S. had been ladling life out of him, and insight in, “one teaspoon at a time” for a decade (Simmons, 2002). In a life-long friendship, he had been my colleague, my mentor, my fellow-performer, my friend. As I give thanks for his wisdom, love, and many gifts, the news of his death brings to mind another existential moment, one that I shared with a young companion just 2 days ago.

We were walking along a path through the woods on a humid, sun-drenched summer afternoon, absent mindedly sharing freshly picked raspberries—pick two; give him one. My powerfully built companion was half my age. Every fiber of his being was focused in questioning, a seeking charged with the muscular urgency of youth. Suddenly, with eyes brimming, he blurted out, “I don't want to die! I don't want to die!” Not that he was more actively dying than we all are, even sick. Instead, he had suddenly been struck by the reality of his eventual fate.

We all have had such experiences. To our dismay, a crack appears in our carefully crafted concept of reality. These existential moments wrench us into a new way of perceiving. How to describe them? They are not simply moments of despair, anxiety, or joy, for, dramatic as those experiences are, we recognize that they are not reality per se, but our response to reality. The existential moment, on the other hand, entails a paradigm shift, a jarring, visceral reframing of reality. The very nature of reality is experienced in a new way. We are sucked into the startling realization that the rules of the game are not what we had imagined. Not only does life depend on unfamiliar rules, it never was defined by the terms we had always held to be reliable.

What to do with such a moment? We have two options. We may choose to ignore the experience and hang onto the comfort of the past illusion—desperately attempting to assure ourself and others that this now irrelevant formula still holds true, or we can take a leap of faith into the void, following the advice of one observer of existential angst who calls out to us:

In accompanying those who are dying over the past quarter century I have come to view life as a spiritual experience, that is to say, a search for meaning, purpose, and personal connection to something greater and more enduring than the self. Joseph Campbell (1988) has seen our path as “the hero's journey.” In his view, we all are heroes on an epic quest! Studies by Cohen et al. (1995, 1996a, 1996b, 1997, 2001) suggest that the existential/spiritual domain is an important determinant of quality of life in that journey, that its relevance to subjective well-being may increase as death approaches, and that it is responsive to skilled palliative care.

The findings of a McGill qualitative research study examining the inner life experience of persons with a life-threatening illness (B. Mount & M. Boston, unpubl. data) support Frankl's (1984) assertion that our quest is for meaning, but in addition, they suggest that meaning is not an end in itself, but a means to an end. That end is an experience of community, attachment, union—with self, with others, with the Other, however perceived.

We need connectedness. The wisdom literature of the East tells the story of the little wave that rejoiced at the magnificence of the vista before it as it approached the shoreline. Later, however, its delight turned to horror as the rocky coast loomed large. “Can't you see?” it exclaimed to its neighbors, “We are doomed. All is lost. We are about to die.” “Don't be afraid” responded a wise companion. “You are not simply a wave. You are part of the ocean.”

Viennese Psychiatrist Viktor Frankl spent 3 years (1942–1945) in Auschwitz, Dachau, and other Nazi concentration camps. Early one frigid morning in the first months of 1945 he experienced an existential moment that changed his life. Frankl and his fellow prisoners were making the daily forced march from the camp to their work site. Whipped by icy winds and prodded by the rifle butts of the accompanying guards, they stumbled on “through large puddles and over big stones,” supporting each other against falling in the predawn darkness. Suddenly the man marching next to Frankl whispered behind his upturned collar, “If our wives could see us now! I do hope they are better off in their camps and don't know what is happening to us.” They continued on in silence, Frankl's mind now having turned to thoughts of his wife. He writes:

In one cataclysmic moment Frankl realized that not even death could separate him from the love of his wife.

Recognition of our need for attachment is common to all wisdom traditions (Martin, 1955). One aspect of the psyche that serves this end has been variously named. In the Hindu Upanishads it is the Atman; for the Jew, the soul. In the Christian tradition it is the Kingdom of Heaven; the mustard seed; the concealed leaven; the pearl of great price; the treasure in a field; the living Christ within. It is the Secret of the Muslim faith; the philosopher's stone of alchemist mythology. In Chinese wisdom it is the diamond center; the square inch in the field; the small round thing, jewel, or pearl. It is the Kundalini serpent of Tantric yoga. For Marcus Aurelius it was the source of strength within; for Quakers, “that of God in every man.” In the chivalric tradition of the Middle Ages it was the Holy Grail. For Meister Eckhart it was the tabernacle of the soul; a spiritual light; a Spark. T.S. Eliot refers to it as “the still point,” “the unknown remembered gate,” “the timeless moment,” and “the point of intersection of the timeless with time.” For P.W. Martin (1955) it is simply “the Deep Centre.”

A recent total esophagectomy for squamous cell carcinoma (full thickness; nodes negative) has brought questions of attachment into sharp focus once again in my life, thus refreshing issues raised as an intern when I had a germinal testicular tumor. It has been a challenging but enriching experience. At such times, four ever-present existential issues reverberate with particular resonance in the unconscious—death (in the sense of existential obliteration), aloneness (the unbridgeable gap between self and all else), freedom (an unnerving absence of external structure), and meaning (the dilemma of meaning-seeking creatures in a cosmos that is potentially without meaning) (Yalom, 1980, p. 25). They provide background noise that unsettles peace of mind. Underlying these stumbling blocks is the profound question “Who am I?” (Osborne, 1970). Our existential moments find their power in directing our attention to these fundamental issues.

To live is to experience loss. In offering his profound insights into “learning to live richly in the face of loss,” Phil wrote:

The existential moment is always a surprise. C.S. Lewis (1959) was “surprised by joy.” The smells and sounds of the predawn, lakeside forest are not new to me, and yet I experience them as if for the first time. Death, how often have I encountered you over the past decades? Deaths of patients, of loved ones, of illusions of permanence, two personal dances with cancer, a plane crash. No, the idea of dying is not new to me! The thing itself, like the predawn moment, is always new when we are truly present to it. I would concur with Phil:

It is in being fully present, without expectations of outcome, that the freedom Phil writes about becomes a source of healing.

As I finish these lines the dawn breaks over the lake before me and I become aware of the richly scented air; the birds busily chirping in the trees surrounding this cabin. One of the dogs stretches and ambles over to the water dish. A vigorous lapping ensues! Life is stirring. The sounds and smells bring me back to the present moment, a sense of clarified stillness and the energy to ring the bells that still can ring.

Wisdom traditions, the paths followed by our patients and our own experiences suggest that a sense of integrity comes through establishing healing connections. That's not quite it. It wasn't that the wave needed to establish connections. It was connected—part of a greater whole. Its challenge was to recognize the connectedness that was already there. Perhaps that is our challenge as well. Out of the hell that was Auschwitz and Dachau, Viktor Frankl (1984) attested to that fact. In Learning to Fall: The Blessings of an Imperfect Life Phil Simmons (2002) brings us a similar message. T.S. Eliot (1943) recognized the same profoundly reassuring reality and wrote: