Abstract:
In the modern era, most of us will die a death that we will see coming, that affords us the opportunity to have conversations of gratitude and reconciliation and to come to terms with the life we have lived. It turns out that peace of mind at the end of life has very much to do with the life we have lived. We also have the chance to plan ahead, by way of an advance directive and crucial conversations with those we will leave behind, about our wishes for treatment and for rituals after death. These are real opportunities for peace—for us, and for those who will grieve for us.
Key Words:
hospice care, crucial conversations, reconciliation, gratitude, palliative medicine
In my work as a hospice chaplain, it has been my privilege to be with hundreds of patients and their families as they lived into the last months, weeks, and days of their lives. This is a time when palliative medicine and hospice care can be especially present, address symptoms and alleviate pain, both physical and existential. But also, it is a time in which we are living with the emerging truth that cure is no longer an option. In this precious and rarified space, we come to understand that finding peace at the end of life has very much to do with what our life has meant, to us and to those we love.
My Dad lived remarkably well with pancreatic cancer for a year. At almost the one-year anniversary of his diagnosis, his scans looked good as he underwent surgery to alleviate a stomach blockage. As soon as they opened him up, they knew—he was full of cancer. They closed him up after placing a gastric tube to make him comfortable and we were told that he had six weeks to live. The surgeon, who was so candid with my dad and all of us, gave us a great gift. It was time to say what needed to be said, and as friends and extended family came to visit, there were heartfelt farewells and many tears.
I think it gave my Dad a great sense of peace to go through with me the home repairs that Mom’s house would need in the coming years. He was finishing up his business as we assured him that we would be there for Mom, in whatever way she would need.
Over these weeks we would catch Dad staring at the family picture above the fireplace—the one we had gathered to have taken the summer before. The photo included him and Mom, their four kids and spouses, and their ten grandchildren. Who knows what thoughts and feelings were alive in him during these times of quiet reflection?
My Dad wasn’t perfect, and I recall one afternoon the hospice chaplain emerging dry eyed from his bedroom asking for a box of Kleenex. We were so thankful he had this man to talk with. A summing up for my dad meant a clear-eyed look at the times he had missed the mark as well. I am reminded of what Leonard Cohen writes in his song Anthem:
“Ring the bells that still can ring
Forget your perfect offering
There’s a crack in everything
That’s how the light gets in.”
A life well lived does not mean a perfect life. As we look at the vast landscape of the life we have lived, finding peace is about seeing the cracks and looking for the light. It is not by any means a report card, and at the same time, our work is, in many ways, to come to terms with all that our life has been. Our ability to do this with equanimity and compassion for ourselves and others is most helpful in our journey toward peace.
Surgeon and author Atul Gawande says it this way in his New York Times bestseller, Being Mortal (2015): “Our ultimate goal, after all, is not a good death, but a good life to the very end.”
In my experience at the bedside, I was deeply attracted to what I came to call the “really real.” As my patient (and his/her family) grew connected to the deep reality of approaching death, the unimportant and trivial would fall to the wayside and what mattered most would come to the forefront. In the space of the “really real,” finding peace has almost everything to do with relationships. As we are able, peace is found in conversations of gratitude and reconciliation, where stories of our shared lives abound.
This was true for my dad. In his last six weeks of life, we were able to forgive and seek forgiveness, express our love and gratitude for his life and what that life had meant to all of us. And importantly, he was able to do the same with dear friends and his family. He was able to express gratitude for his life and the deep sadness of leaving. Both were an integral part of his journey toward peace.
‘A summing up for my dad meant a clear-eyed look at the times he had missed the mark as well.’
This means, that to the greatest extent possible, we need to know the truth of our circumstances. It is in the reality of this emerging truth that meaning and peace can be found. Dr. Sherwin Nuland in his book How We Die (1995) said it this way:
“Of the many ways to die alone, the most comfortless and solitary must surely take place when the knowledge of death’s certainty is withheld. Here again, it is the ‘I couldn’t take away his hope’ attitude that is so often precisely how a particularly reassuring form of hope is never allowed to materialize. Unless we are aware that we are dying and so far as possible know the conditions of our death, we cannot share any sort of final consummation with those who love us.”
We live in a time in which almost all of us will die a death that we will see coming. for most Americans, as recently as 1976 death came suddenly, from acute illness or event (Kiernan, 2006). Today, the opposite is true. We live much longer and the overwhelming majority of us will die gradually, often from a combination of co-occurring diseases associated with aging. Thus, finding peace at the end of our lives is, in fact, not something we are lucky to stumble upon, but is a process in which we can engage, today, tomorrow, and for the rest of our lives.
Ancient wisdom and volumes of contemporary writings speak of the value of reflecting on our mortality and the myriad benefits of not just reflecting on our mortality but also on planning ahead. Both can help to bring us peace, now in the midst of our lives and, importantly, at the end of life. And both require intentionality and courage.
My teacher and friend, Frank Osteseski, says it this way in his seminal work, The Five Invitations—Discovering What Death Can Teach Us About Living Fully (2017):
“To imagine at the time of our dying we will have the physical strength, emotional stability, and mental clarity to do the work of a lifetime is a ridiculous gamble … . Reflecting on death can have a profound and positive impact not just on how we die but how we live.”
The Roman philosopher Seneca teaches: “Let us prepare our minds as if we had come to the very end of life. Let us postpone nothing. Let us balance life’s books each day. …The one who puts the finishing touches on their life each day is never short of time.”
We need not wait to tell those we love how loved they are and how much their lives have meant to how our lives have unfolded. Let them know how grateful we are that the path of their star crossed the path of ours. And if we have unfinished business, now is the time to talk this through. We need not wait until we are on our deathbed to have conversations of gratitude and reconciliation. Anti-war activist, poet, and Jesuit priest, the late Daniel Berrigan, said it this way: “First things, recognizably first” (Boyle, 2010).
Over the years, I have learned this as well. How we die matters. A lot. To us and importantly to those who will grieve for us. We can help by planning ahead, making sure our loved ones know how we feel and what we would choose in the event we can no longer speak for ourselves. Completing an advanced directive and having conversations about our choices is an act of compassion. Our loved ones never forget our last days, the conversations we have, or don’t have. Peace, for us, at the end means to leave those we love in peace, too. So let us have the conversations about what we want and do not want as we are dying—and what we want after our death. It brings peace to the bereaved to know what our loved one wanted—and to be able to see those wishes through.
‘How we die matters. A lot.’
In addition to an advanced directive, another very specific strategy for finding peace at the end of life is to prepare an ethical will for those who will grieve your loss most deeply. An ancient tradition for passing on personal values, beliefs, blessings, and advice to family, friends, and future generations, an ethical will can mean more than any material possession you might bequeath to them. Often prepared in the form of a letter, an ethical will can be a vehicle for clarifying and communicating the meaning in our lives to our families and even communities.
Barry K. Baines, MD, writes: “Those who want to be remembered authentically and for their gifts of heart, mind and spirit take satisfaction in knowing that what they hold most valued is ‘on the record,’ not to be lost or forgotten” (Baines, 2001).
I would suggest that the thoughtful process of preparing an ethical will need not, and should not, wait until one is imminently dying. The process of preparing, and even sharing, such a document now, can bring great meaning and peace in this day and, at the end of your days.
A number of years ago my friend Mark was dying of alcohol-related cirrhosis—he was afraid, guilt ridden, and grief stricken. Told he was not a candidate for a liver transplant; he did not have long to turn toward his leaving. We sat on his porch in the warm September sun and talked about how important how he died would be to his beloved 19-year-old son and to his wife Sarah. As hard as it was, he knew that he needed to express, and they needed to hear, his regrets, apologies, and deep sadness—and he was desperate to express his boundless love. We talked about how his son would live the rest of his life with the memories of how he left him and the world. Mark and his family were heroic in his last days. Through the cracks they found the light. And, I think, peace.
Michael W. Milward is CEO of the California Hospice Network in San Mateo, CA. He can be contacted at mmilward@cahospicenetwork.org.
References
Baines, B. (2001). Ethical Wills: Putting Your Values on Paper. Perseus Publishing.
Boyle, G. (2010). Tattoos on the Heart: The Power of Boundless Compassion. (pg. 39). Simon & Schuster.
Guwande, A. (2015). Being Mortal. Picador.
Kiernan, S. P. (2006). Last Rights—Rescuing the End of Life from the Medical Profession. (1st ed.). St. Martin’s Griffin.
Nuland, S. (1995). How We Die. Vintage.
Osteseski, F. (2017). The Five Invitations—Discovering What Death Can Teach Us About Living Fully. Flatiron Books.
