The Five Things that Matter Most

It happens more frequently than you might realize; a patient with a terminal illness, with every reason to have already passed on, seems to linger.  The family is often gathered, and has spent several days holding vigil and yet their loved one hangs on to life by a thread.

Often at these times the family senses a purposeful waiting from their loved one and a hunt as to why there is a stall ensues. When the patient’s symptoms have all been treated appropriately, and he or she rests peacefully, this several day pause in the transition can weigh heavily on loved ones.

 “I just don’t understand why Dad doesn’t let go!” a daughter will say, as the waiting piles up day in and day out. 

There is a theory that floats around the hospice world as to why some of our patients wait to die. It can’t be proven scientifically, but even if it’s a coincidence, the idea behind the theory is powerful. 

The idea, first written about by a well-known Palliative Care doctor named Ira Byock in a book entitled “The Four Things That Matter Most: A Book About Living” discusses crucial phrases we all need to hear from our loved ones on a daily basis.

However important it is to speak these words routinely, these phrases become paramount as we near our death.  The lingering we see, and can’t explain medically, at times may be a patient waiting in hope to hear these words.

The four phrases that Dr. Byock writes about, and I think every person longs to hear from those dear to them are “Please forgive me”, “I forgive you”, “Thank you”, and “I love you”.  These simple words hold enormous power and encompass so many reasons why someone may not be letting go.  When we die, we all want resolution, absolution, appreciation, and adoration.  This sets the stage for peace and the ability to release oneself.

I personally think there is yet another word that holds even more weight, and it is probably the hardest of all the phrases to say. We utter this word nonchalantly every day to co-workers, spouses and children; however, it lacks the finality that it has when someone is dying.  In fact, despite encouraging families to do this, many can never say this word.  That is, they can’t bring themselves to say “Goodbye”.

What is unrealized is that the power of this word is not in the emotional and physical separation that it implies, but in the permission it grants. Many of my patients lie in a stupor for days, hoping to be granted permission to go, permission to give up the fight, permission to be pain free and at peace. 

Goodbye doesn’t mean that that we want them to die, or that we won’t be devastated once they are gone. Goodbye means we respect them enough to not only acknowledge the reality of their dying, but that we love them enough to give them the opportunity to go if they need to. 

Even if all these phrases don’t seem to change the timing of someone’s death, they are guaranteed to bring healing to those waiting.