Psychiatrists Can Help People ‘Die Well’

In 1995 a study funded by the Robert Wood Johnson Foundation revealed that the way that many Americans die is far from ideal. They may experience physical pain, or they may spend their last days in an intensive care unit, or they may have physicians who have no idea of their wishes regarding cardiopulmonary resuscitation.

But many Americans also suffer considerable psychological anguish during their final weeks or days, Ira Byock, M.D., director of the Palliative Care Service in Missoula, Mont., and a hospice physician for a decade, reported at APA’s 2002 annual meeting in Philadelphia in May. The title of his lecture was “Dying Well: Beyond Symptoms and Suffering—Human Development at the End of Life.”

For some Americans, dying entails a loss of meaning and purpose in their lives, Byock said. For others, it is a time to feel guilty about what they have done or not done with their lives. Still others brood about estrangement from family and friends. Also, it is usually not physical pain but anxiety about being a burden on loved ones that drives dying persons to request euthanasia. But dying does not have to be like that, Byock asserted. Dying can be a much more positive experience—a time for psychological and spiritual growth.

“I have seen some people change dramatically during this time,” he attested. “Some people change in ways that are important to them and their families.”

Byock cited the case of a pediatrician who grew psychologically and spiritually as he was dying. Here is how the pediatrician described the process: “I characterize this time as a gift—a time to tie up the loose ends for my family, to reconnect with people with whom I had become estranged, and also a chance to discover what it is like to have death sitting next to you. I like the person I have become. I now have a spontaneity that I did not have before. Colors, sights, sounds, touches, and hugs are more wonderful than ever before.”

Even though Byock is a family care practitioner, not a psychiatrist, he argued that psychiatrists should become more involved in helping people die well psychologically and spiritually.

“We have left dying to the internists!” he declared. “But what do they know about helplessness and hopelessness? It is time for you psychiatrists to play a leading role.”

Very few psychiatrists have been involved in this area up to now, he added. So what might psychiatrists do to help the dying become whole, to die well on their own terms? Byock offered some suggestions from his own experiences with dying patients:

• Conduct life reviews with dying persons to instill meaning and purpose in their lives. You can ask when they were naughty or did good deeds, who their enemies were, what their preferences or aversions were. You can ask them what it was like when they were at the apex of their lives. “I have done life reviews with patients who could not remember who I was, but they could remember their pasts,” Byock said.

• Help dying individuals forgive themselves. You can tell them, “We are all going to come to the end of life imperfect, so get over it!” Smokers who are dying from lung cancer or emphysema especially need help to deal with their guilt. You might ask them in a jovial way, “Do you think that if you had not smoked, you never would have died?” Then tell them to repeat to themselves, “I am a good person.”

• Help dying persons become reconciled to loved ones from whom they are estranged. You can write down on a three-by-five-inch card what they should say: “Please forgive me, I forgive you, thank you, I love you, goodbye.” Byock wrote such a sentence down on a card for a cowboy who was dying and estranged from his wife and children. The cowboy read the sentence aloud to his wife and children and said that he felt a lot better afterward. So did his wife and children, Byock added.

• Help dying persons realize that it is normal to be dependent on others at this point in their lives and that they should accept such dependence.

• Help dying individuals respond to the mystery of life, to connect to something larger than themselves. For many people it means connecting with a god, and for those who believe in a god, it is indeed a strength. But dying persons who do not believe in a god can derive spiritual comfort in other ways—say, by deciding to be buried on a plot of land that is important to them or to have their ashes distributed in the wilderness.

• Perhaps most crucially, you can help the dying “surrender to the transcendent—to let go,” as Byock put it.

Byock also touched upon how “baby boomers” such as himself can prepare for dying well, even in their middle years. First, accept that you are going to die at some point. Then ask yourself, If an earthquake struck me today, what important business would I leave unfinished?

“Your first thought would certainly not be your Palm Pilot,” Byock chuckled. Then set about finishing that business before it is too late, he admonished his audience. ▪