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Lessons in Dying Well

cancer at home, in New Jersey. With his wife, Ruth, Seymour Byock traveled to California to celebrate his 63rd birthday with their son, daughter-in-law, and first grandchild. No sooner had his parents arrived in California than Byock's father needed to be hospitalized. Instead of visiting for two weeks, he stayed for almost two months. Seymour Byock died at his son's home, a choice that was then very unusual.

As he recounts the experience of caring for his father at home, Byock explains the profound lesson he learned about the limits of medicine—especially hospital-based medicine, where death is considered a problem. "Medicine equates dying with death," Byock says. "But I've learned dying does not equal death. Dying is a part of living, with unique challenges and opportunities."

Learning from dying, and helping people die well, has become Byock's life work. While practicing family and emergency medicine in Montana, Byock helped lay the foundation for palliative care in this country. A past president of the American Academy of Hospice and Palliative Medicine, he was recruited to Dartmouth in 2003 to head DHMC's Palliative Care Program.

Literally on the eve of his departure from Montana for New Hampshire, Byock received a call from his sister. "It was the phone call we all dread," he remembers. At first, all they knew was that their mother had been in a car accident. They later learned that while stopped in traffic, she had suffered a fatal heart attack. Despite the chaos of the sudden death, Byock knows it could have been a lot worse. No one else had been injured. Nothing important had been left unsaid. And his mother had put all her legal and financial papers in order so that they were easy to find. "We felt cared for by my mother, again and again, even after her death. She was ready. She had done it for us. We continued to feel cared for into an uncertain future."

On the eve of his departure from Montana for New Hampshire, Ira Byock received a call from his sister. "It was the phone call we all dread," he remembers.

Before she died, Ruth Byock had read the galleys of the most recent of her son's four books, The Four Things That Matter Most. Those four things, he explains in the book, can be reduced to 11 words: Please forgive me. I forgive you. Thank you. I love you. "I know this stuff works," Byock says. "I draw comfort [from] knowing nothing critical was left unsaid. I apologized for all the worry I caused her when I hitchhiked across country [as a teenager]. I thanked her. I told her I love her."

The fact that his mother left her affairs in such good order has also made Byock a big proponent of advance directives. He's quick to add that he thinks such documents are oftenmisunderstood. "They are not prescriptions," he says. "They are a statement of values and preferences. It's a way for an individual to project their caring into the future." Byock wants to make having an advance directive routine for all patients at DHMC.

This year, his department sponsored the first annual National Health-Care Decisions Day. It was held on April 16, the day after the income-tax deadline. "Death and taxes," Byock explains. "They're both part of life."

Byock has become an articulate and recognized proponent of the need for a shift in the country's cultural climate, fromavoiding to accepting end-oflife issues. "It's time we boomers acknowledge we're mortal," he says. "We're going to die, and we need to integrate that with rich and healthy living."

Byock came to Dartmouth in order to advance the nation's appreciation for palliative care. "This is the place to change the system," he says, "to transform medicine by advancing both cuttingedge medical technology [and] the highest of human values. These are complementary goals, not competitive ones."

It's the getting there

Dr. Deborah Peltier's widowed mother, Peggy Peltier, put all four of her children through college and grad school as a teacher of junior high school English. After her kids left home, Peggy Peltier stayed active and independent and remained involved in church and community affairs. With savvy foresight, she had a ramp and grab bars installed in a ground-floor bathroom when she was only 75, long before she needed such aids. She cross-country skied into her eighties, until a series of strokes finally slowed her down. Well established in her community, she was able to stay in her own home even then. Deborah Peltier's sister, Mary, lived with their mother until she needed constant care, and then she moved to a nearby nursing home.

During the years their mother was at home, the four siblings supported her and one another. The three who lived elsewhere shared the cost of keeping their mother and sister at home and took

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