Monday, August 10, 2009

Learning something new

The aspect of geriatrics and palliative care which never ceases to amaze me is how much I learn from my patients and their families. In many ways I have 24/7 access to an endless 'university' of life lessons. I recently came upon a life lesson that, simple as it seems in words, opened a profoundly new perspective on the life-death journey for me.

In so many palliative care teachings on communicating with patients and preparing them and their families for death, I have learned to ask patients what tasks/goals they feel they need to complete/accomplish before they die. The responses have run the breadth of possibilities: reconnecting with an estranged child, handling finances, seeing a wedding/graduation/birth, finishing a painting, finding a home for a beloved pet. I've come to always ask my patients this important question. Many of my patients have found comfort in the completion of these goals and tell me prior to their death that they have accomplished everything important they feel they need to prior to dying--and that this gives them a sense of peace.

Last week, making a home visit to one of my patients, I asked her how long she felt she had to live and whether there were important things she needed to do. She replied, "Of course. I have many cakes to bake, gardens to see, books to read. I believe people should leave this earth with things unfinished. It's important to do things but I believe you don't want to complete everything. If you do then what is there left to live for and look forward to? I want to have things left to do when I die."

It was so simple and, perhaps, to others not revelatory. Yet, for me, in that exchange, I realized that for years now in my practice, I have always felt it important for individuals to have completed all they feel they need to complete prior to dying. But now I have learned that having unfinished tasks is just as valuable and powerful. In talking with her about her philosophy, I found peace myself.

2 comments:

Alex Smith said...

While I think most people have specific expectations for the end of life, these expectations vary widely. I used to give people Ira Byock's recommended tasks for the dying: saying "I love you, I forgive you, forgive me, thank you, and goodbye." See this article of his for a thoughtful discussion:

Suffering and Opportunity

This went fantastically well for many patients and their loved ones, until one patient said, "That's not for me. It would feel too canned." I still use the tasks, on occasion, but I tend to feel patients out more rather than recommending the tasks prescriptively for all.

Setting expectations high for completion of tasks can offer hope for meaning making and closure. It can also set the bar unattainably high. As Ira Byock notes:

"It is a rare individual who achieves all that he or she had hoped for in life, and this waning phase of life also offers the opportunity to come to terms with life's frustrations and disappointments and to accept one's own imperfections. A clinician who enjoys a good rapport with a patient can point out that the person is "only human" and that humans, by their very nature, tend to be imperfect."

ken covinsky said...

Helen--what an inspiring story! Your patient seems truly wise--and this is yet another lesson on how the best wisdom is expressed with a few simple words.

Your patient's sentiments seem to have a lot of life applications. When we start something, how often do we keep ownership and control for too long? Maybe it is sometimes better to let others run with the ideas we start.