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Dying Well

Slowly but surely, Americans are coming to see death not as a failure on the part of medicine but as a natural part of life. DHMC is leading the way in this movement, as described here. And a pair of related stories recount deaths realized in this manner.

I have learned from my patients and their families a surprising truth about dying: this stage of life holds remarkable possibilities," wrote Ira Byock, M.D., in his 1997 book, Dying Well. To Byock, director of DHMC's Palliative Care Program, dying well means dying free of pain and fear while having one's emotional, social, and spiritual needs, as well as medical needs, attended to.

Byock has been a hospice physician for more than 20 years. His research and advocacy, plus his service as president of the American Academy of Hospice and Palliative Medicine, have earned him a national reputation. Since coming to Dartmouth in 2003, he has been working to improve DHMC's already strong palliative-care program—to bring an even more holistic approach to caring for the terminally ill and injured. "Medicine, as powerful as it is, is just an instrument," he says. "If all we do is improve medical care for people who are dying, all we can hope to achieve is better medicalized dying."

Instead, what Byock wants to do is ensure that people who are close to death still have a high quality of life. Many palliative-care programs focus solely on relieving physical suffering. Byock and his colleagues take a different approach. The DHMC palliative-care team—which includes physicians, pain specialists, nurses, social workers, and a pastoral caregiver—helps patients and their families to better understand the illness at hand and to identify the values and beliefs that will guide their choices. "We


then assist with the personal—meaning the emotional, social, and spiritual—adjustment to their condition, their often uncertain prognosis, and to perhaps progressive illness, disability, and the knowledge that their life expectancy is short," explains Byock. "But it's highly individualized." The team is also reaching out to area hospice programs. Byock says he and his staff have visited almost every hospice program in the region to improve continuity between DHMC and community programs.

"Often people wait until there is no hope of living longer before being referred to or accepting hospice care," says Byock. "We're now trying to use hospice care to give them the very best supportive services so that they have a chance of

living longer." For example, some insurance plans require that an individual who accepts hospice care must forgo potentially life-extending treatments. "People shouldn't have to choose between a treatment that might give them a few quality months to live and treatment or care directed at their comfort and quality of life," Byock maintains. Dartmouth has a chance "to lead a constructive revolution in health care, where attention to the personal needs of the individual patient and family become part of the mainstream," he adds.

Byock's hope is to make dying really about living, to temper what he calls the "shrill, piercing, overwhelming amplitude" of grief for those left behind. When counseling people who have just lost a loved one, he often tells them to "just remember to breathe—at this moment, all you have to do is take the next breath."

In the two stories that follow, the authors describe wrestling with their hopes and fears about an imminent death—one after a life measured in decades, one after a life measured in hours. Death at an advanced age, Byock says, is sad but "offers an opportunity to celebrate . . . a full life," while the death of a child can leave "an overwhelming sense of loss, not only for what has been but for all that might have been." Yet "at some point, parents often are able to look back and acknowledge the gift that their child was in their lives," he adds. "In a sense, we are all transient gifts to one another."

—Jennifer Durgin

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