Practicing Gratitude by Dr Ira Byock

All the passages below are taken from Ira Byock’s book, “The Four Things That Matter Most”, published in 2004

Meister Eckhart, a fourteenth-century Christian theologian and mystic wrote, “If the only prayer you say in your whole life is `thank you,’ that would suffice.”

Please take a moment to thank someone you love when he or she smiles at you. The next time you put your child to bed or before you and your spouse retire, try enumerating everything he or she did that day that touched you, that fulfilled his or her responsibilities in your life together, that acknowledged the connection you share.

By paying attention to the details of the ways in which people give to us and show us care and consideration, we become more mindful of our own lives. We begin to focus on our own good fortune rather than our problems. If we practice this consistently and diligently, feelings of gratitude can pervade our lives.

Biographies of Joy

In a remarkable small book, Joy, Inspiration, and Hope, Jun­gian psychiatrist Verena Kast talks about helping people create biographies of joy. This technique helps her treat people for depression and counsel people who are ap­proaching the end of life. I have also found this a particu­larly powerful approach to help people look at their lives in a positive, constructive way, especially when they are strug­gling with grief over lost loved ones or friends.

“Joy tolerates no isolation,” Kast writes. “Joy is the emo­tion that lets down our guard, for better or worse. Joy opens us up…. Joy is the state in which we are least likely to reflect on ourselves. In the moment of delight, we are; there is nothing we have to do … when we are joyful, we feel self-confident and accept ourselves, knowing that our existence is not a mat­ter of indifference. To put it the other way around, when we accept ourselves, we are likely to be delighted in and feel ac­cepted by the world, experiencing an affinity with that which transcends us, with other persons, and with the spiritual.”

You can begin to create your own biography of joy by thinking back to when you were a small child. How did joy feel in your body? Are you someone who tended to giggle or sing when you felt joyful? As you grew a bit older, what continued to give you joy: Christmas mornings, birthdays, a special family trip? In your teens, what evoked joy? Per­haps you felt joy after a successful piano or dance recital, or when you scored a goal in soccer or football. Perhaps you remember a time you felt especially close to your father or mother, or the first time you fell in love.

What happened to joy in your life? For too many of us, joy has been lost. Perhaps we thought it was self-indulgent or childish. But joy is a legitimate part of life—a necessary, essential part of healthy living.

What gives you joy? Playing with babies or young chil­dren? Visiting with friends or family? Art, music, old movies, mystery novels, or comic strips? It’s important to bring joy into your life on a regular basis, even if this notion feels self-indulgent. Consider joy as part of your recom­mended daily dose of essential vitamins. “Vitamin J” is vital to your well-being.

It’s interesting that when I ask people in the throes of terminal illness to talk about what elicited joy in their past, a remarkable thing often occurs. Even if they’re suffering, as they recall events in their childhood their expression changes: they smile and sometimes laugh aloud.

It is not unusual for people who are terminally ill to ex­perience this state of joy when death is close. Each moment and each human interaction becomes precious. People who are dying don’t take things for granted. In the naked hon­esty and vulnerability that accompanies proximity to death, even seemingly inconsequential interactions—or simply the presence of another person—can be revealed for the miraculous gifts that they are. Gratitude and joy are inti­mately fused, and practicing gratitude is a sure way to bring joy into our lives.

In the act of saying thank you we expand ourselves. Thank­ing people in an explicit way is an act of generosity. By naming what we have been given, we remind ourselves of the surfeit of our experiences, of how replete we are. We invest attention in what we have, rather than what we lack. In most cases, we realize that we have what we need. We begin to recognize how much we’ve been given.

People at the end of life can seem to lose themselves in the past. They feel drawn as if by gravity to the density and richness of their accumulated life experience. They often express intense gratitude about their lives and for the people they have known. An old French proverb says, “Gratitude is the heart’s memory.” In gratitude we celebrate who we are to one another and the ways in which our lives have been shaped and moved by each other.

People who are dying seem to grasp the abundance of their life experience. Even as life is slipping away, even as they face ultimate loss, people can feel filled with grace and love. This aspect of dying—this actual, attainable sense of completion and deep peace—is especially common to people who have family support that includes humane, loving palliative care.

I had my own experience with the power of gratitude and the transformation that catalyzes at the end of life. I was personally given the gift of gratitude in a way that I’ll never forget.

A Lucky Man

When I met Ernesto, he was dying from colon cancer. As the hospice medical director at the time, I usually saw patients if there were problems with which their own physician or my hospice nurse colleagues wanted help. In Ernesto’s case, the team wanted me to make regular visits because I spoke more Spanish than the rest of them.

During my residency training and practice in Fresno, many of my patients were from Mexico and only spoke Spanish, so I had had to learn enough to take medical histories and perform physicals. And I wanted to talk with them! My take on doctoring has always been that if you can’t kibitz with your patients, what’s the point? During my residency I grew to have a special fondness for Mexico and its people, and today I visit the country whenever I can.

Driving out to meet Ernesto for the first time, I wondered if he would have any interest in the emotional aspects of this time of life, including the Four Things. From treating Hispanic boys and men, I had seen that many have difficulty dealing with what might be called the softer emotions, and that “machismo” is a male survival trait in some cultures. Respect is earned by tolerating risk and pain, and by appearing invincible. How would machismo fare in the face of death?

I pulled into the trailer park of a low-income neighborhood in Missoula where Ernesto lived. He was up and dressed for my first visit. Clearly “the doctor coming” was an event worthy of preparation. He was just 61 years old, but looked much older. The skin was loose and bruised beneath his eyes; creases were etched into his forehead and cheeks. His thin, gray hair was neatly combed and his mustache newly trimmed. He showed no sign of physical distress. He was bright and even animated at times. Meeting him socially, one might not have thought he was ill. But that day, looking through clinical eyes, I guessed to myself that he had lost about 30 pounds since the denim shirt he wore had fit.

Ernesto spoke a moderate amount of English; his wife, Julia, a little less. My questions and our subsequent discussions in a mix of Spanish and English were challenging, and, at times, hilarious for us all.

There was a gentility about them both that transcended language, and I was fascinated by their history. Ernesto and Julia had both been born in Mexico and had initially come to California as young children of migrant farm workers. It was a hard life. Migrant children were rarely in the same school more than a month or two. The couple had met and married in Salinas in their teens and traveled together, following available work.

Julia became pregnant a few months later. They were picking cherries in central Oregon when a complication with the pregnancy forced them to stay beyond the harvest. After being hospitalized for a week, the couple was taken in by a local family. With the help of a local church group Ernesto found a job as a janitor with the school district. The pregnancy continued to term and their first daughter was born in Oregon, a United States citizen. They stayed in Oregon for 10 years and both Ernesto and Julia also became citizens.

Following my first visit, Ernesto’s cancer progressed rapidly. He seemed to shrink a bit each time I saw him—except for his liver, which was swollen with cancer metastases and tender, its edge felt easily three fingerbreadths below his right ribs. I continued to make visits to their home every couple of weeks. Most of the time Ernesto was in pajamas, lying on the couch when I arrived. I was able to control his pain with morphine tablets, three times a day. I added Prednisone, both to decrease inflammation around his tumors and as a “tonic” to boost his appetite and sense of well-being. During this time, despite continued weight loss, Ernesto had many more good days than bad.

Ernesto, Julia, and I could usually dispatch these physical and pharmacological matters in about 20 minutes and spend the rest of my visit talking. I learned that they had moved to Missoula when their second child was two and Ernesto got a job as a janitor in the local high school. There was no shame in it for him. He took pride in his work and considered himself a lucky man. Both daughters had graduated college, the first two to do so in their extended family. Their eldest was now married with children of her own. Through careful spending and saving they had no debts and had gathered enough in the bank to ensure that Julia would not have to worry about basic bills after Ernesto died.

My contribution to our hospice team’s psychosocial care consisted mainly of stating the obvious—I expressed admiration for all that he, and they, had accomplished.

“Soy un hombre afortunado [I am a lucky man],” Ernesto often told me. “Me siento tan agradecido para los regalos de todo el dios [I feel so grateful for all God’s gifts].” He said, “I have always thought so, but I have never realized quite how fortunate I was until now!”

Ernesto and Julia knew their time together was limited. In the same manner in which they had made decisions over the years about what to do with limited money, they carefully chose to invest their time with family. With my encouragement, Ernesto organized the family photo albums. During weekend visits, their daughters and sons-in-law taped Ernesto and Julia talking about the photos: their parents, long dead; their early life together, following the harvests, their daughters as young children; Ernesto as a strong, handsome young man; the journey of their lives from the hills of northern Mexico to Missoula. They were making heirlooms for their grandchildren.

Las Cuatro Cosas

On my last visit, Ernesto was in a hospital bed in the front room of their trailer. The disease had drained nearly all his energy—he could muster only enough breath for a few words at a time—but he was awake, lucid, and not in pain.

He rested half sleeping, but, when I engaged him, his eyes became bright and he found the energy to smile broadly. I briefly examined him, noting that he had breath sounds at the base of his lungs that sounded like Velcro being pulled apart. These were from fluid in the small air sacs in his lungs and had been there the week before. A small pressure sore on his tailbone from extended bed rest was clean with no signs of infection. Neither would cause distress. I asked Julia if he was still able to swallow pills (he was), how much fluid he was drinking each day (just a few cupfuls), and when he had last voided (that morning). We stood by Ernesto’s bedside so that he could hear, and, if necessary, disagree with her responses.

Julia and I made no attempt to hide the fact that time was short. I said that although we had plans in place for any emergency, I fully expected that Ernesto would gradually become more and more sleepy, and die quite gently. Julia said their daughters were now visiting daily and taking turns spending nights with Ernesto, helping their father turn in bed, sip some juice, or even use the bedpan, so that she could get some uninterrupted rest. I hadn’t met the couple’s daughters during my midweek, midday visits, but I understood from Julia, that they were openly affectionate with Ernesto.

I reviewed the Four Things—“las cuatro cosas“-and Julia nodded and said that their affairs were in order and there was nothing left unsaid. They had taken my advice and expressed forgiveness and thanks as a family and were secure in their love for one another. Any concerns I had had about machismo inhibiting Ernesto’s capacity to complete relationships were clearly unwarranted.

It was not without reluctance that I began to get ready to leave. I knew this was probably the last time that I’d see Ernesto, but I assured them that I’d be checking on them regularly and reminded them that there was always a hospice nurse on call and that the nurse, or they, could get to me within a few minutes if there was a problem. I gathered my notebook, stethoscope, and coat and had my hand on the doorknob, when Ernesto motioned with his hand for me to come back. Julia asked him what he needed, wondering what was wrong, but he just wordlessly motioned again.

In a few steps I was at the bedrails. Instead of speaking, with his hand in the air, Ernesto again motioned for me to come closer. I leaned down so I could hear whatever it was he wanted to tell me. In a single swift motion he reached his arm around my neck and with surprising strength pulled me toward him and kissed me on the cheek. “Te amo, Doctor. Gracias, mi amigo, ” he said, before letting me out of his embrace.

I was surprised, to say the least, by Ernesto’s display of affection, but not nearly as startled as Julia. I looked up to see her standing motionless, tears in her eyes. “I have never seen him do that. I don’t think he ever kissed a man in his whole life,” she said. I told him in my broken Spanish how honored I was to know him and that I would never forget him.

Lying on his deathbed, Ernesto appeared not merely peaceful but radiant. In his dying, Ernesto’s capacity to experience and express gratitude had expanded, and, paradoxically, he had grown more fully alive. His thanks to me was infused with deep feelings of contentment and composure. He was ready to say good-bye. As a doctor, I felt satisfied that my patient was well during this time of his dying. And, as a man, I was profoundly moved. [103-112]