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Grand Rounds

A call for closure

By Ira Byock, M.D.

The summer of 2009 will be remembered as a low point in the decades-long quest to reform America's troubled health-care system. Those of us hoping for substantive improvements cringed when a modest provision in a House of Representatives bill—to reimburse doctors for discussing advance-care planning with patients—was characterized as an attempt to convene "death panels" and to "kill Granny." Town hall meetings were hijacked by opponents of health-care reform, becoming political theater and vitriolic expressions of distrust of the President and Congress.

Counterpoint: It was ironic, yet somehow fitting, that during this same summer Senator Edward Kennedy was dying. The way he faced the end of his life stands as an enlightened counterpoint to the senseless and cynical political kerfuffle. Having championed the cause of health care as a right for so long, he could now only offer us an example of living and dying well.

The Grand Rounds essay covers a topic of interest to the Dartmouth medical faculty. Ira Byock is a practicing physician and the director of palliative medicine at DHMC. He is also the author of the books Dying Well and The Four Things That Matter Most.

When asked, most Americans say that they would prefer to die suddenly. "When the time comes, make it quick and easy" is a typical response. That perspective is understandable. Dying is hard, both physically and emotionally. But dying slowly offers opportunities foreclosed by the unexpected demise that most people say they desire. Having seen so many who were close to him die—too often through violence—Kennedy understood that how a person dies greatly affects those they leave behind.

Early in my career, while practicing emergency medicine, I witnessed many sudden deaths—usually from heart attacks or car accidents, sometimes from homicide. Family members were often inconsolable. It was as if an appendage had been abruptly amputated, leaving them stunned, devastated, and bewildered. During this time, I also began serving as medical director for a home hospice program. In stark contrast to the families of those who suffered traumatic deaths, bereaved families of hospice patients, while inevitably sad, often spoke of a sense of satisfaction, saying they were grateful to have had this time together.

Opportunities: Over the years, I have come to see dying as a critical stage of human development. It represents a personal crisis with profound dangers, but it also brings opportunities. The dangers are all too familiar. In addition to pain and other physical distress, an incurable disease gradually robs a person of the activities and roles that underlie his or her sense of purpose.

In the midst of this hard, unwanted time of life, it may appear unseemly to call attention to developmental opportunities, but to ignore them is to miss a valuable part of our human endowment. Kennedy clearly understood this.

In counseling people who are living with an advanced illness, I often ask if there would be anything important left undone if the person were to die suddenly. It is a way of framing the difficult but normal work of completing a life.

Families of hospice patients, while inevitably sad, often spoke of a sense of satisfaction, of gratitude for time together.

"Getting one's affairs in order" usually refers to transferring a title on a car or a deed on a house, updating one's will, and otherwise lessening the costs and legal and bureaucratic burdens families experience after someone dies. The phrase also aptly applies to tying up loose ends related to work and social commitments, including finishing or turning over special projects and responsibilities. Kennedy likewise took time to advance projects he held dear. He showed up when President Obama signed the national service bill he had championed, and he helped get a health reform bill through the Senate Health, Education, Labor, and Pensions Committee he chaired.

People who know they are dying typically value a chance to say goodbye to colleagues, neighbors, and acquaintances from the daily and weekly routines of their lives. With close friends and relatives, perfect relationships are worth aiming for but rarely achieved. More vital is the willingness to apologize and offer forgiveness. Knowing that one's days are numbered offers the possibility, if one chooses, of mending strained relationships.

Legacy: A number of commentators have referred to Senator Kennedy's last year as a "celebration lap." Indeed, when there is nothing left unsaid between people who love one another, time together often takes on the qualities of celebration. A sense of delight infuses the simplest of things—sharing cups of tea, taking a drive, or spending an hour on the porch watching a rainstorm or a sunset. People often indulge in telling old stories, or, like the Kennedys, singing songs they have crooned together innumerable times. Some families record those stories or songs as a legacy for generations to come.

Kennedy evinced all of this in his dying. The eulogies and reminiscences that followed his death made clear that he had left nothing unsaid. He took life review to a new level by writing True Compass, an introspective and honest memoir. He invested fleeting time and energy in celebrating life and the many people whom he loved and who loved him. In so doing, he offered all of us an example of what it means to die well. Kennedy completed his life in a manner consistent with his personal values and, from all accounts, he felt well within himself despite the physical ravages of his cancer.

We will rightly remember Ted Kennedy for his prodigious legislative accomplishments and the place he earned in American history. But we should also take note of the integrity and wisdom with which he completed his remarkable life.

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