Trees and forest.Photo by Long Lim/Flickr, cc by-nc-sa 2.0

It's difficult to believe these days, when so many of us have had some experience of moving toward death with a loved one in hospice, or even a stranger on the CaringBridge website, how "badly" people died in this country until very recently. That's the word Dr. Ira Byock uses. He began his life in emergency and family medicine and recalls that when people were deemed to be dying — when what was wrong with them was beyond "fixing" — they too often died in pain in the hospital or were simply sent home. Doctors practicing now still recall their training, implicit and explicit, that death was a failure of the body, and of medicine. We turned away from it, scientifically and culturally.

The palliative care and hospice movement arose first in England and then took hold in the U.S. in the 1970s and 80s to compassionately treat the pain of chronic illness and all the suffering — physical and otherwise — as the end of life approaches. Its spread has converged with the continued advance of medicine. In our lifetimes, many forms of cancer have transformed from fatal diagnoses to chronic illnesses.

As I was preparing for my interview with Dr. Byock, I re-read a gripping New Yorker article by the surgeon Atul Gawande. It chronicles the increasingly blurring boundaries between treating illness, prolonging life, and staving off death. When one woman asks him if her sister is dying, he realizes, "I wasn't even sure what the word ‘dying' meant anymore."

Dr. Ira Byock with PatientsDr. Byock sees this as a human opportunity and challenge. Medicine is remarkable, he knows from the inside, and will continue to get more remarkable with the passage of time. But we must "grow the rest of the way up" and acknowledge that we have yet to make one person immortal. Even while we fight for life with all the tools at our disposal, we have to reckon with the reality of death. The good news, as he tells it, is that there are riches to be gained in that reckoning. That edge of life — which our miraculous medicine allows some to perch on longer than ever before — can be a time of unparalleled repair and celebration. Like it or not, as Dr. Byock says, death completes us. These days more than ever before, we can shape that moment of completion together with those we love.

With this kind of thinking, Dr. Byock is taking the impulse behind hospice to a new place. He goes so far as to suggest that dying can be a developmental stage of human learning and actualization — like adolescence or mid-life accomplishment. He names "the four things that matter most" — words that can be transformatively spoken and enacted — at the end of life: Please forgive me. I forgive you. Thank you. I love you. These are four sentences, a mere eleven words, with a power to call up a lifetime of struggle in so many of our families.

I think here of that phrase attributed to Oliver Wendell Holmes that has recurred so often in my interviews: the "simplicity that lies on the other side of complexity." For in the time of life we call dying, as Dr. Byock describes, these elemental human capacities like thanks, love, and forgiveness can unfold in their most complex and immediately redemptive power. The Four Things That Matter Most by Ira ByockI love this quote of the theologian Paul Tillich, which he put in the preface of his book The Four Things That Matter Most, and which points at the way being with dying has opened Dr. Byock's imagination about the word "forgiveness":

"Forgiving presupposes remembering. And it creates a forgetting not in the natural way we forget yesterday's weather; but in the way of the great "in spite of" that says: I forget although I remember: Without this kind of forgetting no human relationship can endure healthily."

One difficulty of this conversation is that there are no rules for when, in any life or any course of medical treatment, we can know we have crossed the boundary between fighting death and facing it. Dr. Byock suggests that this is not an either/or but a both/and. Still, there is something fierce and sacred in us that resists the end of our life and the death of those we love. That same impulse resists the kind of contemplation that happens in this conversation as well. One of Dr. Byock's most basic insights may be his most helpful: we must remember that, even in the 21st century, death is never really a medical event but a human and personal event. Dying is a defining feature, strange and mysterious as it remains, of living.

Share Your Reflection



Listening to the show calls to mind a poem by Buddy Wakefield, which includes the line "...Forgiveness is the release of all hope for a better past."

I always love the show but this morning's interview is truly exquisite! Yes the life force is powerful, the instinct to survive is mighty! When i have witnessed deaths, when the struggle ends, there is such a feeling of relief in the room. Thanks for this. Thank you.

I have noticed in my life, the older people that I have seen pass on, come to a realization of a certain essence for them, possibly. It's a tender part of life, I think.
But at what point in life one reaches there greatest integrity may not always be of utmost importance at that time. Sincerity is another word to use, I think. Lord bless us our human condition. Amen.

Thanks for inspiration. It helps my work as chaplain in cardiac icu where the potential of death as a stage of human development has huge potential to ease fear, allow death, avoid bardos and limbos of suffering for everyone. Wonderful!

I am a HOSPICE R.N. and it can be very rewarding time . People are letting you in their life at a very personal ,intimate time ! People tend to die as they have lived ! The most peaceful deaths are those when people accept and embrace death !

Well said. And also another horrible stonewall in our health and medical systems is the neglegence of nursing homes. My grandmother died a horrible death of institution-induced dehydration. It was not a mere case of benign neglect, the orders were instructed by the Bethany Good samaritan Nursing staff Director to stop giving my grandmother liquids. We are in the midst of a suit agaisnt the Administration there. This has been happening all over the state. People are labeled with senile dementia when they are not, so they can be brought down the list to illiminate dietary sufficiencies, and then let slip away, pushing the family out of the know, and filling the obituaries. This needs to stop one way of another.

That's sorrowful. I believe what you say, and it's sorrowful. At the poverty level, in my experience, I would rather slowly die than place myself in their care. How does one make it stop? I have no idea.

Erik, one more thing, personally I would look to the Muslim community for help with this issue. That's what my heart tells me. Sincerely, Pat.

I was very touched by this inteview. I am a Geriatric Nurse who works closely with Hospice and Palliative care staff when my Residents reach their final journey at the end of their life. I usually work more closely with the Hospice RN's that come into te facility that I work. I was so moved and inspired to hear a Physician's thoughts in your interview with Dr. Ira Byock's mission and his dedication to provide care for those at the end of their lives. I have learned more about things I can do to help my patients and their families during this "Time of trasnformation from life into death." (Statement made by Dr. Ira Byock) 

After my wife died in hospice care I became a volunteer. I am an 11th Hour, Home Care, and Bereavement volunteer. This is the most rewarding thing I have ever done.