Life Lessons at the End of Life

If I had my life to live over again, I would form the habit of nightly composing myself to thoughts of death. I would practice, as it were, the remembrance of death. There is not another practice which so intensifies life.
– Novelist Murial Spark            

Throughout history, death has been portrayed in various ways, albeit almost always in negative terms. In most accounts, death is cast in the role of the antagonist, a formidable foe who knows no grace and shows no impartiality. But that is not the only way to view death. Ironically, patients, spiritual leaders, and healthcare providers working with those at the end of life also speak of death as a teacher, reminding us that in spite of the many losses at this stage of life there are also a number of potential life lessons offered to us within this mortal landscape. This article offers insights into some of these positive life lessons that seem to present themselves alongside losses at this stage of life.  As you read this article you may want to reflect on the following:

  • How does my previous experience, or lack of experience, with death and dying shape my current experience?
  • How might my experience of my patient’s dying help me prepare for my own dying?
  • If I knew I had a limited time to live what would I want to do with the time I had left? Who would I want to spend it with? What would I want to do?
  • What would I consider to be a good death for me?
  • What do I consider to be true? How is my life currently aligned with these beliefs?
  • What regrets do I carry with me and how do they affect my life? How can I come to peace with them?
  • How might my spiritual beliefs be a source of comfort in facing the end of life?
  • What worries me about death and dying?
  • What can I do now to prepare for my own dying?
  • How do I want to be remembered?

Death as a teacher

The idea that death can serve as a teacher has long been affirmed by spiritual leaders and philosophers. Gandhi once said, “Man lives freely only by his readiness to die,” while Socrates reminds us that “Nobody knows what death is, nor whether to man it is perchance the greatest of blessings, yet people fear it as if they surely knew it to be the worse of evils.” While death and dying are indeed a serious and sad stage of life, these great thinkers suggest that death need not be a morbid topic, but may contain within it nuggets of wisdom that are not easily produced in other stages of life. The notion that death can provide insight on the self and life is echoed in the old adage shared among healthcare providers caring for individuals and families at the end of life—‘Patients are our greatest teachers’. Having the privilege of sitting at the bedside of dying patients as a spiritual care professional over the last 14 years and being privy to a number of these life lessons, I can attest that this is not simply an expression used to make family members feel better or to help healthcare providers personally cope. When confronted with the notion of death, priorities shift drastically. Work, bills, salaries and status rarely seem to make it into a patient’s lesson plan, whereas enhancing meaning, spending time with family, being yourself, remaining true to beliefs and values, relinquishing control, and growing in acceptance and kindness are prominent themes for those reflecting on their lives. And while much of these discussions do not provide answers to life’s big questions, they do invite us to reflect on the things that really matter.

This notion of death as a teacher can even extend past patients and families to include those healthcare professionals working in end-of-life care as well. A study of Canadian healthcare providers working in palliative care inquired about the impact that death and dying had on their personal and professional lives.1 Contrary to conventional wisdom that would presume mostly negative responses, they instead described the impact in largely positive terms. While recognizing that death and dying arguably represent life’s greatest challenge, guarding against a romanticized view of mortality, they shared a number of valuable lessons that may be helpful to us as we experience this phase of life. In particular, individuals working in palliative care felt that death enhanced their sense of meaning in life and allowed them to apply these life lessons into their life prospectively in contrast to their patients who had attained this wisdom from hindsight. Two other important life lessons that healthcare providers spoke about addressed the topics of death-related fears and the key ingredients of experiencing a good death, which are discussed briefly below.

Death-Related Fears

We all have fears associated with dying ranging from no longer recognizing our loved ones, to experiencing uncontrollable pain, to no longer being who we once were. Fortunately, the majority of these worries fail to come to fruition.  As a dying patient once told me, “I now realize at the end of my life that the things I spent the majority of my life worrying about, rarely happened.”  It seems that fear keeps good company with uncertainty, as we rarely are scared of things we know about—the boogey man under our bed disappears once we turn the lights on. In the same way, palliative care professionals reported that the fears that patients held in regard to their death and dying rarely occurred; and, if they did rear their ugly heads, there were interventions and support services that could minimize their impact. While, for example, we may experience incidences of pain and symptom distress at the end of life, it is important to realize that the vast majority of patients fortunate enough to die in Canada, experience very good pain and symptom management and overall wellbeing. In addition to addressing our death-related fears prospectively, healthcare providers felt that perhaps the greatest medicine in normalizing death and dying was exposure, as experiencing the dying process of friends and family seemed to bolster resilience and resources which could be drawn upon when facing one’s own death and dying. 

A Good Death

Palliative care providers identified a number of key ingredients of what they termed a ‘good death’—a death that is marked by meaning, good pain and symptom management, and a high degree of wellbeing. Remaining oneself and participating in one’s death, rather than being a bystander, were identified as essential features of a good death, while being curious about what might lie beyond death also served a supportive function. The notion of having no ‘unfinished business’ also featured prominently in descriptions of a good death. Being at peace with loved ones was particularly important, reminding us that it is best to resolve family discord well before our final moments. Tightly held preconceptions of what constituted a good death were actually felt to inhibit the possibility of a good death, as remaining open to the possibility that one’s death might not occur precisely as planned was another, albeit ironic, key element of what healthcare providers considered a good death.

Conclusion

When it comes to death and dying, most of us would prefer to learn through distance education rather than personal experience. Unfortunately, if there is something that we can be absolutely certain about in life, it is that we will all personally experience mortality, our own and that of those we love. And sometimes it is within these greatest of hardships where we are offered the most important of lessons. It is through the lens of patients, their families and healthcare providers who work in end-of-life care, where we can garner the greatest knowledge about overcoming fears associated with death, and learn to be receptive to the positive life lessons that reveal themselves when we are confronted with death. Through these individuals, we can be reminded that as well as bringing loss and challenges, death can teach us a thing or two about living and dying well. We just have to be open and receptive to learning.

References

1. Sinclair S. (2011). Impact of death and dying on the personal lives and practices of palliative and hospice care professionals.  CMAJ 183(2)180.