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Vital Signs

End-of-life expert Ira Byock will lead palliative care unit

People whose lives were ending seemed to be falling through the cracks of the health-care system. Or so it seemed to a young doctor named Ira Byock, M.D., as he was doing his family medicine residency in the late 1970s in a Fresno-based program of the University of California-San Francisco. "As a sideline almost, being a good citizen at the medical center," he says, "I lent my time to helping what became a little fledgling hospice program get off the ground."

Advocate: Now an internationally renowned advocate for highquality end-of-life care, Byock was recently named director of DHMC's Palliative Medicine Service. He believes Dartmouth is poised to become a recognized leader in end-of-life care.

Ira Byock, the new director of palliative care at DHMC, is a prominent advocate for better integration between the U.S. systems of curative and palliative care.
Photograph: Mark Austin-Washburn

"Our health-care system, and frankly our culture, are hungry for leadership within this realm," he says. "Dartmouth and the northern tier of New England are in a perfect position to assert that leadership." Byock feels that way because of DHMC's commitment to patient- and familycentered care and its alreadystrong program in palliative care. In addition, he points out, northern New England has many regional and local coalitions and groups "working toward improvement in the quality of the end of life."

Byock speaks and writes eloquently about dying as a natural part of human development, about how, just as it's possible to live well, it's possible to die well. In fact, Byock's first book was titled Dying Well. Published in 1997 by Putnam, it has become an authoritative resource on end-of-life issues.

In March, the Free Press, a division of Simon & Schuster, released his newest book, The Four Things That Matter Most: A Book About Living. It describes the importance of being able to say to loved ones: "Please forgive me," "I forgive you," "Thank you," and "I love you."

"There are discernible tasks or areas of human development that turn out to be very commonly important to people at the end of life," Byock explains. "It has to do with completing our relationships in the world—in our communities, with friends and acquaintances, as well as with close friends and family.

Good-bye: "Once you've said those things, often you are able then to say 'good-bye' whenever the good-bye has to happen," says Byock. "With those few words—11 words—I've seen so many relationships be transformed at the end of life. And people's quality of life often paradoxically rises, becomes so much more peaceful, settled, satisfactory, full—ironically, when they're facing life's end."

Yet today's health-care system doesn't make such an approach to end-of-life care easy, Byock maintains. "We labor under a health system here in which, mostly through Medicare, people who are seriously ill are forced to choose between care for prolonging their life and care for comfort and quality of life.

"Right now," he explains, "the best-developed and only paid, comprehensive form of palliative care is hospice care, which is brilliant and extraordinary in its power. But you have to give up the care that you're getting through your oncologist or your cardiologist or your neurologist— whatever you're receiving for your illness—to get hospice care."

Models: But, Byock continues, "we have an opportunity in northern New England, through demonstration projects, to look at new models of delivering palliative care with life-prolonging care." In other published interviews, he has drawn a parallel between end-of-life care and pediatric care, noting that a wellchild visit is precipitated not by a problem but simply by the need for some oversight of the normal but risky events of infancy. Similarly, he feels, care at the end of life should focus on that stage as part of normal human development, rather than as a problem.

Back when Byock was training to be a doctor, he never intended to become one of the world's gurus of palliative care. A graduate of the University of Colorado School of Medicine, he thought he was preparing to become a small-town physician in the Rocky Mountains. But he got interested in hospice care while he was still a resident.

Hospice: A few years later, after working in emergency and family medicine in Montana, he began serving as hospice medical director at Partners in Home Health Care in Missoula, Mont. In 1992, he became the director of the Palliative Care Service, a clinical consulting and teaching practice also based in Missoula. And in 1996, he cofounded "Life's End Institute: Missoula Demonstration Project" and served as its president and principal investigator.

Nationally, Byock directs the Robert Wood Johnson Foundation's Promoting Excellence in End-of-Life Care Program and is a past president of the American Academy of Hospice and Palliative Medicine.

Byock's wife, Yvonne Corbeil, has also joined DHMC's Palliative Medicine Service, which is based in the Department of Anesthesiology. She was assistant director of palliative medicine at McGill from 1981 to 1996, before joining the Life's End Institute.

"We needn't wait till death is knocking at our door to realize that the treasures in our lives are the people we love or have loved," says Byock.

Laura Stephenson Carter

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