Open Conversations

Yesterday in my Senior Health Forum that I run in Del Mar, we discussed the end-of-life. In the past when we have broached this "loaded" issue, I have been surprised that this topic seems to grab the audience more than any other. Yesterday was no exception. I invited 2 good friends (Joseph and Michael Rubano) to talk about the recent passing of their father. I asked them to be our leaders because I considered their father's passing to be a "successful" end of life. This concept of "Dying Well" was discussed in depth in the book by this name by Ira Byock MD (president of the American Hospice Movement). I have sought out this goal above all others in my practice of medicine. I always remember and truly believe the quote by Ram Dass "the most important moment of any incarnation is the moment before death". I heard this many years ago and have valued the concept highly ever since. My own father did not have a "good end of life" as I would define it and quite possibly this is why I am so drawn to this as an overriding goal.

What makes for a "good" end of life? How can we help guide people toward this lofty goal? I believed Lou Rubano's end demonstrated what I would define as dying well. While he had many medical challenges in his lifetime, his end was marked by: (1) Clear consciousness until very close to the time of his passing (2) Loving presence all around him at the end (3) Peace and acceptance by him and from his close family relatives as his life wound down (this was most definitely not always the case for him) (4) pain and adverse symptom control and (5) A spiritual connection on his own terms.

Interestingly, these 5 issues are independent of the medical condition(s) that bring one to the end of life. In other words, a "good" end of life can come to one regardless of the circumstances that lead up to the event. The challenges are universal and thankfully reachable with the right frame of mind. The hospice movement has helped our world gain access to this world of possibility. Having hospice guidance CAN facilitate a "good" end-of-life but does not guarantee it. People often choose hospice only when there is nothing else to turn to to hold onto life. This is understandable but is a gross "under use" of the hospice experience. The hospice experience is meant to bring closure to the end of a good life. It is holistic (in that it values the body, the mind and the spirit). It functions best when it is utilized fully in all these realms and not just as a symptom management process. It is very good at symptom management; the nurses and doctors are true experts with pain medicines and the full arsenal of medications available to provide relief of any and all negative symptoms (ie nausea, pain, fear, depression). However, the entire experience goes more smoothly and more beautifully if the entire model is accessed. When a person is open to the mind and the spirit, there is a whole higher level of peace that is attained. This level is benefitted if the individual has been open to and nurtured these concepts during their life. Thankfully, individuals often open to these "non-body" realms as their time draws near.

The age old principles of forgiveness and acceptance really show their power and strength in this setting. Medicines can provide symptom relief but acceptance, forgiveness and love bring a peace that cannot be attained with any drug. The senior years and the end-of-life are really about these issues--not about the body.

Connection to one's self, one's loved ones, and one's perception of a higher power are the core issues. The body is a teacher and a vehicle for learning but the heart of the matter is really in the relationships to one's self and to others. When those relationships are characterized by love, acceptance, forgiveness and understanding, there is a lit path to a good conclusion of life.

The good news is that we CAN create a good end-of-life. The challenge is to focus on these "spiritual" issues and not get "bogged down" in the body issues. Of course, we all should try to maximize the function and duration of the body but when push-comes-to-shove, peace comes from connection, peace and love and these are attained through acceptance and forgiveness.

Michael and Joseph brought home these concepts to our group as they openly discussed their father's transition. The entire audience was both moved and motivated. I am truly grateful to them for their wisdom, beautiful and truthful communication and their wide-open hearts. They shined a light for our group and now it is our turn to let the light shine. The truly beautiful thing about it all is: when we learn how to die, we can truly begin to live. These principles do not have to be saved for the end; they can be harnessed in life and for life.