Dr Ira Byock on Healing comes from Asking and Offering Forgiveness
All the passages below are taken from Ira Byock’s book, “The Four Things That Matter Most”, published in 2004.
Please forgive me.
I forgive you.
I love you.
These four simple statements are powerful tools for improving your relationships and your life. As a doctor caring for seriously ill patients for nearly 15 years of emergency medicine practice and more than 25 years in hospice and palliative care, I have taught hundreds of patients who were facing life's end, when suffering can be profound, to say the Four Things. But the Four Things apply at any time. Comprising just eleven words, these four short sentences carry the core wisdom of what people who are dying have taught me about what matters most in life.
The Wisdom of Stating the Obvious
Ask a man who is being wheeled into transplant surgery or a woman facing chemotherapy for the third time what's on his or her mind and the answer will always involve the people they love. Always.
The specter of death reveals our relationships to be our most precious possessions. I've lost count of the number of times I've met people in my office, an emergency room, or a hospice program who have expressed deep regret over things they wish they had said before a grandparent, parent, sibling, or friend died. They can't change what was, but without fail their regrets have fueled a healthy resolve to say what needs to be said before it's too late--to clear away hurt feelings, to connect in profound ways with the people who mean the most to them.
Everyone knows that all relationships, even the most loving, have occasional rough spots. We assume that the people we love know that we love them, even if we've had our disagreements and tense moments. Yet when someone we love dies suddenly, we often have gnawing doubts.
We are all sons or daughters, whether we are six years of age or ninety-six. Even the most loving parent-child relationship can feel forever incomplete if your mother or father dies without having explicitly expressed affection for you or without having acknowledged past tensions. I've learned from my patients and their families about the painful regret that comes from not speaking these most basic feelings. Again and again, I've witnessed the value of stating the obvious. When you love someone, it is never too soon to say, "I love you," or premature to say, "Thank you," "I forgive you," or "Will you please forgive me?" When there is nothing of profound importance left unsaid, relationships tend to take on an aspect of celebration, as they should.
A deep, natural drive to connect with others lies at the heart of what it means to be human. The Four Things can help you discover opportunities to enliven all your important relationships--with your children, parents, relatives, and close friends. You need not wait until you or someone you love is seriously ill. By taking the time and by caring enough to express forgiveness, gratitude, and affection, you can renew and revitalize your most precious connections.
The Practice of Good-bye
It's been said that life is a sexually transmitted condition with a terminal prognosis. Having worked for years in close proximity to death, I have come to understand viscerally that we live every moment on the brink. We are, each one of us, at every moment, a heartbeat away from death. Seen against the backdrop of our certain mortality, our differences are dwarfed by our commonality--and the importance we hold for one another.
The stories in The Four Things That Matter Most are drawn from the experiences of people who have stood at death's door, and from their loved ones who learned to use the Four Things in their own daily lives. These stories inspire us to open to the potential for emotional wholeness at any moment in our lives--even in our most troubled relationships.
When I work with people who are approaching the end of life, I emphasize the value of saying the Four Things and I also encourage them to say good-bye. The Four Things offer essential wisdom for completing a lifelong relationship before a final parting. Thankfully, not all good-byes are final--but good-byes can be meaningful. It's important to say good-bye in a way that affirms our relationship and acknowledges our connection to one another.
The word good-bye derives from "God be with you," a blessing that was traditionally given at parting and, in some churches, still is. The protection and God's help of presence and guidance can be requested whether two people expect to be separated a few hours or forever. In leaving nothing unsaid, we can recapture this original meaning, so that, in saying good-bye, we are actually blessing one another in our daily interactions as well as when we face major life challenges or crises. It only takes a moment to shift the way you say good-bye from a reflex to a conscious practice. Your good-bye and your blessing can become treasured gifts to other people as you part.
Expanding the Realm of the Possible
Our world is bounded by our imagination. This may sound philosophical, but I mean it in a most practical, tangible sense. Helen Keller once wrote, "Worse than being blind would be to be able to see but not have any vision." When a formerly cherished relationship is marred by unkindness, bitterness, or betrayal, we often assume that healing is beyond our grasp, but this assumption can create a self-fulfilling prophecy. Do you really want to have such a limitation on your vision for your life?
The extraordinary experiences of the people whose stories I tell in this book demonstrate that healing and wholeness are always possible. Even after years of alienation, of harsh criticism, rejection, or frustration, you can establish or re-establish--authentic understanding and appreciation of others with the help of the Four Things. Even as people confront death (their own or others'), they can reach out to express love, gratitude, and forgiveness. When they do, they consistently find that they, and everyone involved, are transformed--for the rest of their lives, whether those lives last for decades or just days. Stories and experiences of people who have courageously used the Four Things enlarge our vision and imagination, expanding the realm of the possible for us all.
The Four Things are powerful tools for reconciling the rifts that divide us and restoring the closeness we innately desire. When bad feelings occur in our close relationships, we tend to put off the work required to make things right. We always assume we'll have another chance . . . later. That's understandable, but it's a mistake. Feeling resentful toward the people we love, or once loved, feeling distant from them, erodes our own happiness.
A brush with death often instills in us a newfound appreciation for the gift of life. Simple pleasures--a cup of tea, sunshine on one's face, the voices of our children--feel like miracles. When we've had a close call that shakes us up, the anger we've felt toward people closest to us no longer seems significant. Ill-will dissolves in love, appreciation, and affection, and we recognize the urgency of mending, tending, and celebrating our relationships.
Because accidents and sudden illness do happen, it is never too soon to express forgiveness, to say thank you and I love you to the people who have been an integral or intimate part of our lives, and to say good-bye as a blessing. These simple words hold essential wisdom for transforming that which matters most in our lives--our relationships with the people we love.
The Healing Power of Words
Edwina Hargis was a patient in an ambulance speeding toward the emergency room where I was an attending physician. "Code 3," the ambulance radioed, meaning lights and sirens. "A seventy-eight-year-old woman with sudden, severe abdominal pain radiating to her back. Hypotension down to seventy by palpation."
Abrupt onset of acute abdominal pain that radiates into the back and dangerously low blood pressure can mean several things, none good: it is a classic presentation for a leaking abdominal aortic aneurysm. The diagnosis can pretty much be confirmed by a physical exam during which the paramedic feels a "pulsatile abdominal mass." In fact, that was the next thing the Emergency Medical Team reported. So I had a good idea of Mrs. Hargis's diagnosis by the time she arrived. Indeed, I had already alerted Surgery that we were getting a patient with a ruptured "triple A," and to keep an operating room open. After being stabilized in the ER, my patient would likely be coming to them STAT, within 15 minutes.
When Mrs. Hargis arrived, she surprised me by saying that she was already well aware that she had an aneurysm. Furthermore, she knew it was gradually expanding and that, when it ruptured, it would be lethal. She needed major surgery to have any chance of surviving, yet other health problems--including diabetes, hypertension, coronary artery disease, and peripheral vascular disease--made it unlikely that she could survive an operation, which was the best treatment for her life-threatening condition.
I pulled up a stool to the head of her gurney. "I wish I had better news for you, Mrs. Hargis. From what you've just told me, it sounds like you understand the situation. Like a bleb on a bicycle tire, this aneurysm has been getting bigger over many months. Today it has begun to leak. As you've said, and the doctors have told you, you might well die in surgery. Without surgery you will almost certainly die within the next few hours. Do you understand?"
Mrs. Hargis had listened to my grim report with her eyes half closed. Now she nodded, as if to herself, then opened her eyes and looked at me with firm resolve. "Yes, I do," she said. She knew the score and had discussed it more than once with her internist and cardiologist. "I've known this day would come. I do not want surgery. I'm prepared."
The nurses and I were making her comfortable with medications and intravenous fluids as her family arrived in a private waiting area outside the ER.
"Mrs. Hargis, I want to let your family know what's happening. Is that all right?" I asked.
With my patient temporarily stable, I left the trauma room and met Mrs. Hargis's daughter and two sons. I explained her medical condition and her decision to decline surgery. Gently but explicitly, I informed them that without surgery her death was imminent. I was brief and to the point because I was aware of how precarious Mrs. Hargis's condition was at that moment. Time was short.
Her children were not surprised. When she had made her decision not to have surgery, almost two years ago, she had explained it to them.
As I was speaking with Mrs. Hargis's family, the nurses had cleaned the trauma room and brought in a few stools for them so that they could visit their mother until a room was ready upstairs. Before they went in, June, her eldest child, a woman in her forties, asked, "How is she doing now, doctor? And what is going to happen next?"
"At this moment, your mother is doing okay," I replied. "We're giving her pain medication and fluids. Hopefully, this will buy a little time. Let us know if you feel she is hurting too much. As the bleeding continues, her blood pressure will fall and she will become less alert. When her blood pressure falls too low, she will die. It may happen gradually, but it could be sudden. She may have only a matter of minutes or a few hours to live. I realize that this is precious family time, and we'll do all we can to preserve it."
We went into the trauma room together and I told Mrs. Hargis that I had explained the situation to her family. Then I said, "I want to suggest something to all of you that may seem obvious, but I hope it's worth saying. Whatever time you have together today is a chance to say the things that would be left unsaid. In fact, `stating the obvious' is important at times like this. Over the years I've learned from my patients how important it is to say four things: Please forgive me, I forgive you, Thank you, and I love you. By saying these things, people often feel better prepared to say good-bye."
"You're on the mark, doctor," said June. "Mom doesn't talk much about feelings. She loves us and I think she knows how much we love her," she looked at her mother, and then back at me. "Mom grew up in a ranching family with three brothers. They weren't outwardly affectionate. And `I love you' was not something we said a lot to each other growing up. But there's no time like the present." She turned to her mother, "I love you, Mom!" The nurses had lowered the guardrail so June was able to lean over and hug her mother.
I excused myself, left the family, and called the operating room to tell them they could stand down. Instead of rushing to surgery, Mrs. Hargis and her family were going to use the time together to say or do whatever mattered most to them. The nurses got everyone to a private hospital room and the family asked a priest to come to administer the Sacrament of the Sick. Three hours after admission, Mrs. Hargis's blood pressure fell and she became unresponsive. A short while later she was pronounced dead.
Later that same evening, Mrs. Hargis's daughter came back to the emergency department before leaving the hospital and asked to speak with me. She said her family wanted us to know how much they appreciated the nurses' and my care of her mother. She said, "This was the best possible way for the worst possible thing to happen. My mother was a strong, stoic woman. If she had died suddenly, there would have been important things left unsaid. Your advice was so helpful. She told each of us kids how proud she was of us. That's something we had never heard her say! I told her that we would never forget her. It was stating the obvious, just as you suggested." She smiled. "Thank you for taking such good care of us all. I never realized just how much words could mean."
The words that Mrs. Hargis and her children had given one another in those last hours of her life were profound gifts. Her children will carry those blessings with them for the rest of their lives.
The Lifelong Benefits of the Four Things
Our core relationships do not, in all ways, end with death. The people who are most important to us become part of our psyche and soul. Even after their death, people who have been most central in our lives naturally continue to influence our thoughts and feelings. Saying the Four Things is important for our ongoing relationships to the people we lose through death. One day, after we die, our children and loved ones will benefit from having said the Four Things to us.
Occasionally, cynics have confronted me by saying, "It's just not that simple!" Well, it is and it isn't. I have never--and would never--imply that it is always easy to find the intimacy and warmth that we yearn for with the people who mean the most to us--or that we will all find meaning in facing our mortality. Sometimes, rather than bringing people together, serious illness pushes them apart and fractures relationships. Emotional and physical pain can try the gentlest of souls; fear can shut us down and close us off.
Yet I also know that healing and wholeness are possible--and often straightforward--even in the wake of personal troubles and tragedies, even in the face of death. I have seen them occur too many times to ignore this aspect of our human potential. And because of my work with patients of many ages, backgrounds, and life circumstances, I know that this kind of healing is not just a matter of luck. As a doctor, I cannot heal relationships between other people any more than I can will the grass to grow. I can prepare them for healing, plant some seeds, keep careful watch, and nurture any evidence of growth. In the plowing and planting and tending of the emotional, spiritual healing process, words are my most valuable tools. They can become yours, too.
Instruments of Healing
We often underestimate the power of words as instruments of healing. Specifically, we don't recognize the power that comes from talking with one another about our feelings and our most private, intimate fears. Here again, these sensitive subjects tend to surface when people are very sick or not expected to survive, or a loved one is about to leave on a long trip or work assignment. It's one thing to avoid talking about living wills, death, or funerals while we are playing bridge or bowling, but it's quite another to continue to avoid such subjects when an ill relative or close friend is growing visibly weaker with each visit. Culturally, we walk around the proverbial elephant in the living room without ever acknowledging the weight of separation, departure, illness, or impending death on all our lives.
Actually, we don't just avoid such conversations, we actively squelch them. It's not that we are uncaring. It's sort of automatic. Say we're with a close friend, cousin, sibling, or parent who is ill and not getting better. In the course of reviewing the recent tests, or medications, or bills, she shakes her head and mutters, "Sometimes I just wish it would be over."
"Oh, don't talk like that," we say reflexively. I've caught myself doing it, too, even with all my experience with talking and dealing with people and their lives at the end of life. It's so culturally ingrained to be optimistic and reassuring that the words are out of our mouths before we know it, like saying "Gesundheit" when someone sneezes. But we need to recognize seemingly offhand comments for what they often are--an invitation to listen. And then, perhaps, to talk.
People have often told me, "I would talk with her, but I don't know what to say." I really believe that the Four Things will help you in such a situation. First and foremost, though, the best way to help someone who is ill, lonely, depressed, or dying is by just showing up. Being there communicates to the person how much he or she really matters to you. When you are present with someone you care about, be willing to open your mind and heart. If you are at a loss for words to say, the Four Things can help you.
The emotional and physical benefits to our health and happiness that come from connecting with others have been repeatedly demonstrated by psychological and medical research. Even our judicial system recognizes this human drive in its penal code: short of execution, solitary confinement is the worst punishment permitted by Western law. Isolation and abandonment cause suffering in people of all ages and cultures, even in the absence of illness. For people under stress, dealing with illness, or facing change, emotional isolation can be torture. Far more than pain or any other physical symptom, isolation evokes feelings of helplessness and hopelessness. This isn't only true when people are dying--it's true for everyone.
In addition to our primal drive for connection, we each have an instinctive impulse to give and receive love. We have a deep desire for healing and wholeness. Thankfully, honest, heartfelt, well-chosen words have the power to heal and make us whole. I'm not referring here to the power of prayer or chants, all of which may offer great comfort, but to the pragmatic healing potential of words like the Four Things--words that are personal but also universal.
I've seen such words rescue people from the abyss of hopelessness and despair. The Four Things have lent strength, renewed faith, and rekindled hope in the face of uncertainty. They affirm our deep connection to one another. Through well-chosen words, we can celebrate our communality, our humanity, and our individual uniqueness.
It is a quirk of our language that the word complete implies finished or over, but a relationship can be complete without ending. Conversely, a relationship may end, but remain incomplete. The word complete doesn't always imply finality. A circle that is complete, for instance, is whole and never-ending.
We are complete in our relationships when we feel reconciled, whole, and at peace. People say they feel complete when, if they were to die tomorrow, they'd have no regrets--they would feel they had left nothing undone ... or unsaid.
Saying the Four Things can help us attain this sense of completion and renew the circle of our most significant relationships, reclaiming the life-affirming love from which they began. Such was the case of an Israeli couple named the Polanskys.
Overcoming Past Hurts
People who are dying recognize how fleeting and precious life is and often feel a sense of urgency about completing relationships. An Israeli grief counselor, Lynne Halamish, told me about an embittered couple in their mid-sixties, the Polanskys, for whom the Four Things proved to be a powerful tool as they grappled with her dying and their fractured relationship. In the late stages of uterine cancer, Mrs. Polansky was too ill to engage in serious counseling work and didn't have long to live. So Lynne spent most of her time with Mr. Polansky and told him about the Four Things. She had just begun when Mr. Polansky said, "Look, I can say forgive me. And maybe, because she's dying, after all, I can say I forgive you. I think I can even say thank you. But I cannot say I love you to this woman."
Lynne asked to hear the whole story. Mr. Polansky described their early relationship. "When I first met this one," Mr. Polansky said, cocking his head toward a photo of his wife in their living room, "I was absolutely head over heels in love with her. But in a very regular, constant way, she has betrayed me personally and publicly with other men over the years. Adultery. One man after another through years of our marriage. It has been a long time ago now, and so I do think I can forgive her, but I no longer love this woman--she burned that out of me. I will not tell her that I love her."
Because Lynne believes--as I do--that we gain strength from saying all of the Four Things, she pressed Mr. Polansky a bit. She asked him how the couple slept at night.
"Back to back, of course," Mr. Polansky told her and shrugged. She then suggested that he try something. Lynne told him that, when his wife lay asleep next to him, he could try to bring to mind the woman with whom he had been so in love. She asked him to take his time and imagine his wife as she once was. "Reconnect with her in your mind, and, if possible, in your heart," she said. "As you hold the woman you married in your thoughts and heart, whisper very, very quietly to your wife's back, `I love you.' You don't have to do this, it's just an idea. Maybe it's a crazy idea, but it's worth considering."
Mr. Polansky was skeptical, to say the least. He asked Lynne what would happen if he said "I love you" to his wife. She confessed she didn't know and asked him, "What do you have to lose?" Lynne explained that there was little likelihood of reforming his wife in her last weeks of life, but that he had a lot to gain from reaching some sense of completion and closure in his marriage.
Mr. Polansky told Lynne he would think it over. As it happened, she didn't see him again before Mrs. Polansky died. She called him to extend her sympathies. A month or so later, Mr. Polansky contacted Lynne and asked if he could come see her at her office. When they met, he said he wanted to tell her what had happened.
"I did what you suggested," he began. "We were lying in bed in the dark and I closed my eyes and pictured her as she was when we met. I whispered to her back, `I love you.' I said it to her, but I could see my young bride in the woman beside me. Before long I actually started feeling the love that I once had for her. I hadn't felt that way since I was in my thirties. After a while I woke her up and told her I loved her. And she said something to me she never said in all our years of marriage. `You are such a beautiful man. My rock.' She put her hand on my cheek and had tears in her eyes. Then she said, `You saved me.' We kissed, and I knew in that moment that underneath it all she had always loved me”.
Lynne asked him what it meant to him to have her say that. "I got her back," Mr. Polansky replied. "The last weeks of my wife's life were the best time in the past twenty years of our marriage. I will miss her, but now I can say good-bye."
Re-creating a Lifelong Relationship
Using the Four Things as practical tools, we can deliberately decide to make our relationships whole. This can bring about a sense of completion before death is imminent. When we accomplish this in the relationships that matter most to us, it often opens a new chapter in our lives, as it did for Diane and Herb Cahill.
"Although my father provided well for my mom, my brothers, sister, and me, I always had the feeling we were more responsibilities to him, than a family that he really loved or wanted," Diane said in describing her relationship with her father.
When I met Diane Cahill, she was in her early fifties, tall with sandy hair and eyes highlighted by fine wrinkles at their corners from years of squinting, or smiling, in the wind and sun. I noticed her eyes because she looks directly at people when she talks. Diane had grown up in a small community north of Boise, Idaho. Her father, Herb, had been a county agricultural extension officer.
"We lived in a separate world from our father," Diane continued. She chuckled. "He was like a boarder. He would come home from work, eat dinner, then disappear into his shop in the garage. Or he would go to a local bar, play cards, and hang out with his friends. On weekends he worked in his shop--pursuing his only real interest, which was woodworking." Here Diane paused. "He did make my sister and me beautiful pieces of furniture, jewelry boxes, and trinkets for our birthdays and Christmas. That was his way of showing affection. But he never hugged us or expressed any warmth. In fact, he had a wicked temper. Although he never beat us (probably out of fear of what my mother would do), he occasionally spanked us, and he was always showing us `the belt' that he kept `just in case."'
For most of her adult life, Diane saw little of her father. Then, at 74, Herb did an abrupt about-face. He reached out to his family and friends. "He called me up out of the blue," said Diane. "He had never done that before. And he asked to come see me. I couldn't believe it. On the phone I was flustered, almost speechless. I lived within forty minutes of him and my mom, but he'd never before taken an interest in where I was living or what I was doing. Lo and behold, the next day he came by my apartment and asked my forgiveness. I was in shock."
Diane said that he apologized to her for not having been around when she was growing up, and for not being much of a father. "For the first time in my life, he told me he loved me," she said. "You could have blown me over with a feather. He actually had tears in his eyes. He said he was proud that I had become a teacher.
"It wasn't just with me. He started going around to all of us in the family, almost everyone he knew, in fact, asking forgiveness for things he'd done or, in my case, not done.
"He told people how much they meant to him. He was very deliberate about it. He was very specific with everyone. He paid off debts--even those that had long ago been forgiven, or forgotten. I can't tell you how many people I've run into who have told me about these visits with my dad."
I asked Diane what had prompted this change.
"For a long time, we didn't know what to think. When I asked him, all he would say is, `I figure it's time I got my life straight.'
"We were baffled, to say the least. Looking back, my mom and I have pieced together that he'd lost an old Navy friend about three months before he started making amends. Then his barber keeled over at work."
I asked Diane about her relationship with her father since his change of heart. She shook her head, as if I had missed the point.
"Only a few months later, my father died."
"Oh, so he had been ill during this time?"
"No, what's strange is that he wasn't ill at all. He was in his shop, turning the leg of a table that he was building on a lathe, and the machine blew up. It was a freak accident. My mother heard a loud bang and ran out to the garage. Dad was lying dead on the floor, his safety goggles on, pieces of the table scattered around him. We never found out what, exactly, killed him. The coroner's best guess was that he'd been electrocuted. Whatever happened, I'm certain that my father didn't know he was going to die."
"Did people give your father the forgiveness he sought? Did you,"
"Oh, yes," said Diane. "He was so sincere. It may sound funny, but I was actually happy for him. He was softer, more genuine. We had such a wonderful time those few months. We had a real father-daughter relationship for the first time. It was a shock to lose him so soon after he had reached out to us. The whole family was devastated. But, without a doubt, it was easier because of what we had all shared in those preceding months. My mother feels the same way. When she talks about him, she's sad, but she's told me that she also feels proud of him--as if in some way he made it! We all got the feeling that he was content with himself before he died, probably for the first time in his life."
I asked Diane if she thought there were any lessons in her father's story that she would carry with her. She thought for a moment. "I never realized just how much was missing in my life until my father reached out to me. It was as if something that was broken inside me suddenly felt whole. I know he felt the same way. There was a deep sense of peace and warmth. I guess the lesson for me is that it's never too late to say what needs to be said," she said. "But it is also never too early. Because you just never know."
Diane and her family took to heart the lessons of the last days of her father's life. To this day, they make sure they say the Four Things to each other regularly.
Coming Current in your Relationships
Interestingly, people who are physically well often feel the same pressing need to complete relationships as people who are dying. You don't need a grave diagnosis or a brush with death to "come current" in your relationships. Herb had the right idea. We never know when we're going to die. Completing our relationships by saying the Four Things to the people who mean the most to us is a way of reaffirming and invigorating what's truly important in our lives.
By saying the Four Things, Mr. Polansky experienced a sense of completion and closure with his wife that he never dreamed possible. He was able to reawaken feelings for her that he thought were long dead, but were, in fact, actually dormant.
For both the Polanskys and the Cahills, completion meant closing a circle that had been broken. When serious disruptions have impaired the connection between people, completion means acknowledging rifts, recognizing difficulties, and reconciling relationships. In both cases, a family's life was transformed and the legacy left was marked by joy rather than pain. And part of that legacy is a resolve to maintain and renew loving connections with other people in their ongoing daily lives.
Whenever we are able to open up and become vulnerable and honest with ourselves, we allow the opportunity for profound transformation. People who acknowledge that their lives may soon be over tend to have little patience with pretense, including their own. In the naked honesty that accompanies death's approach, many people feel a need to apologize for having been self-centered, irresponsible, or just plain wrong.
Most people who are dying still have the capacity to change in ways that are important to them. Their transformation can also make an enormous, and lasting, difference to the people around them. Even the least introspective person may begin to look inward. Serious illness can allow people to experience the immediacy of life. Hard, angry, suspicious people (who, it seemed, would stay that way to the bitter end) often soften, becoming vulnerable and even trusting. I look at these changes not as deathbed conversions, but as quantum leaps in personal development opportunities to achieve a state of mind and an intimacy with others that might not otherwise come to pass.
We know that our family and friends are the most important parts in life, but we tend to get distracted, enmeshed as we often are in the work and family responsibilities that fill our daily lives. Saying the Four Things before we or they confront eternity is a way to honor and affirm the primacy of our relationships. The Four Things help us align our words and deeds to what matters most.
In my public talks and clinical workshops, I have often used Steve Morris as a case to illustrate how the Four Things can point us toward this type of transformation.
Becoming Well Within Yourself
When our hospice team met Steve, he was dying hard. Struggling for every breath, he was unable to walk without gasping for air, yet unable to sit still because of the anxiety that defined his life. Steve was scared of dying, and he suffered through every waking moment of every day.
By vocation Steve had been a lineman for the phone company before a heart attack and emphysema forced him into retirement. By avocation he was a real Montana cowboy, living for his horses, winning numerous riding competitions and the affection of many for his willingness to teach horsemanship to any child eager to learn. In appearance and in his lifelong smoking habit, Steve was also the proto-typical Marlboro Man. A man's man, he was not one to express emotions or even admit to having them. More often than not, work and his horses had come before relationships--and family.
Now he was at the end of his rope. The specialists had exhausted every hope of cure, including hope for the lung transplant he had desperately sought. Steve was the one dying, but he was not the only victim of his condition. His wife, Dot, was his constant companion, nurse, handmaiden, and co-sufferer. If she were out of his sight for more than a minute, he would ring his bell or utter a dampened shout in high-pitched panic, "Dot. Dot!"
It took our hospice team two weeks and a combination of pharmacology, counseling, and pragmatism to gain Steve's confidence. We were meticulous in giving him medication to relieve anxiety and tension. We also taught him to use relaxation tapes, and made suggestions regarding placement of his recliner that helped him breathe easier and not feel so isolated. We had hospice volunteers relieve Dot of caregiving for an hour or two here and there so that she could shop for groceries, see her own doctor, and get a few moments of rest. All our efforts, drawing on our experience and resources of palliative care, helped diminish--at least slightly--Steve's breathlessness and paralyzing fear.
As we learned more of Steve's personal history, however, we realized that his anxiety stemmed in part from the fractured nature of several key relationships and the complex, conflicted nature of his family's life.
One Thursday, while I was visiting Steve and Dot at their home, we talked about his relationships with his family, about some of his regrets, and about his wishes for the people he loved. Then I taught him about the Four Things.
"Before any significant relationship is complete, before it's brought full circle," I said, "people have to say four things. Please forgive me, and I forgive you--because if this was a significant relationship, there will always be some history of hurt between them. Thank you. And I love you."
"Those are really good, Doc." Steve responded with unexpected enthusiasm. "Write those down for me, will ya?" he asked in his muffled, gravelly voice.
Using one of the 3 x 5 cards that I kept in my shirt pocket for jotting myself notes, I wrote the Four Things. Before leaving, I scheduled another visit in five days.
When I arrived the next Tuesday at noon, Dot stood waiting for me behind the glass storm door of the entry to their home. Steve and Dot were clearly eager to relate the events of the past weekend. On Sunday their children and grandchildren had come over for dinner. As they assembled around the table, Steve had announced that he had some things he needed to say. He began, "You know the doctors tell me that this emphysema is finally going to get me. And I know I haven't always been the best father, or husband. Well, there are some things I want to say." With his eyes on my handwritten list, he said the Four Things in his own words.
The effect on everyone there was remarkable. Although Steve's anxiety did not disappear, its grip weakened on him in the wake of his remarks. When he asked forgiveness from the people he cared most about, he said that he had suddenly felt transformed. He was able to tell them how much they meant to him and how much he loved them. Steve's life didn't become easy, but it did become less anguished. After that day, everyone reported that there was now a tenderness and a cohesiveness among them that no one could remember having felt before. One of Steve and Dot's adult daughters told me that this was the first time in their lives together that she and her siblings were able to show affection openly to their father.
As he faced his life's end, Steve was transformed and so was everyone around him. He was happier with himself than he could ever remember being, he said. Paradoxically, in the process of dying, he was healing and becoming well within himself. And in healing his own emotions, he helped his children heal theirs--for the rest of their lives.
Filling the Void
Transformations of this magnitude in response to saying the Four Things are not isolated or rare.
One day, I told Steve's story during a lecture at Johns Hopkins University. Afterward, a large, middle-aged black man came toward me as I was leaving the auditorium and surprised me by abruptly embracing me. At first I was taken aback. People were filing from the hall and here I was enveloped by an obviously emotional man, twice my size. He explained that he served as a chaplain at an inner-city public hospital in Baltimore and needed to tell me his story. Like many of the most affecting stories that I've heard over the years, it was about transformation at the very end of life.
A few months earlier, the chaplain had been paged to the bedside of a 33-year-old man who was dying of AIDS. Just two hours earlier the patient, Antoine, had found out that he had a teenage daughter and that she was on her way to the hospital to see him.
"I was terrified about saying the wrong thing," said the chaplain. "I thought, `Why me? What can I possibly do that would be of any help?' Then I remembered about saying `the Four Things.' I was present for Antoine's and his daughter's meeting and used the Four Things to guide their visit. Antoine needed little encouragement, or help, to ask, `Can you forgive me?' and to say, `Thank you for coming to see me,' and `I love you' to this frightened, anxious 15-year-old girl. And Chantelle, who really does have her father's eyes, was able to say, `Thank you for being my father'; `Of course, I forgive you'; and then, `Daddy, I love you, too.'
"They visited for just over an hour, each hungry to ask questions and tell stories. There were lots of tears; it was hard to separate the tears of sadness from those of joy. Ultimately, Antoine's fatigue and breathlessness forced their visit to end. They kissed each other as they said goodbye."
Listening to this story, I was trembling, but the chaplain wasn't done. "I checked on Antoine later that evening and found out he had died within three hours of the visit."
This work will keep you humble.
Measuring Your Time by Its Depth, Not Its Length
Antoine's life had been transformed in his last hours--he died knowing that he had a daughter, a daughter who loved him. Chantelle's life was also changed forever. She now knows she had a father who loved her, who saw her as she was. He apologized, asked for her forgiveness, and she willingly gave it. She misses all that could have been, but feels fullness in her heart where there had previously been emptiness and pain.
Many people come to the end of their life with fractured relationships. But as the stories of Herb, Steve, and Chantelle show, the healing of a broken relationship in the last hours, or even minutes before death, can reframe the history of the relationship and the biographies of everyone involved. The Four Things can help us be honest and open. They present an extraordinary opportunity, one that is available to us all to use in our lives to heal any relationship, any day.
Of course, not all relationships are fractured. Sometimes, our only regret is death's relentless approach or another parting of ways. In these cases, the Four Things offer a way of expressing sadness over the loss of a shared future and rejoicing over the gift of a shared past. By employing the Four Things in such circumstances, you measure time not in length, but in depth.
In situations in which time is extremely short, being prepared to say the Four Things can help make the best of the worst situation. Sometimes the Four Things come to us naturally, especially the need and desire to say, "I love you." The people trapped on the upper floors of the World Trade Center and in the high-jacked planes on September 11, 2001, called their loved ones to say it one last time. It was the most important call they ever made. Saying "I love you" and expressing the spirit of the Four Things is a priceless gift for those who live on. The knowledge of being loved, even when you are separated from each other, sustains you and provides you with inner strength and comfort.[3-33]