Wednesday, August 15, 2018

Book Review: “The Four Things That Matter Most” by Ira Byock

by Ben Skoch (@skochb)

As someone new to the field of hospice and palliative medicine, I recognize that “The Four Things That Matter Most” by Ira Byock has been around for some time. As I sit down to write this review, I’m reminded of a joke from comedian Jim Gaffigan when he referenced people who want to talk about movies many years after they are released. That being said, the book was new to me as I picked through the 10th Anniversary Edition, and it’s easy to see why this book could easily have many more anniversary editions in the coming years. I was indirectly nudged to read this work while on my inpatient hospice rotation as I counseled a patient’s loved one along with one of my attending physicians. While the specifics escape me, I recall this person having a hard time finding the right words to say to her dying spouse. My attending plucked this book off the shelf, gently held it out for this loving wife, and said, “This should help.”

Byock highlights an important premise in his opening lines when he writes, “We live each day just a heartbeat away from eternity” (xvii). I think most people in the hospice and palliative care world readily accept this. For others, it is easy to hide these thoughts in the dark recesses of the mind, which can often lead to postponement of important conversations and decisions. “It’s never too soon” to have the most important conversations with the ones you love, and as you make your way through these beautiful and sometimes heart wrenching stories, you will see why.

I’ve learned most effectively through stories during my training, when I can tie a concept to a person who I have encountered along the way, so clearly this is one reason I enjoyed this book so much. Byock drives home each of his “Four Things” with touching stories from families across the country. It’s helpful to see how different families are able to say “‘I forgive you,’ ‘Please forgive me,’ ‘Thank you,’ and ‘I love you’” in the face of some terrible emotional wounds. While these stories alone will make the book absolutely worth your time, there are a few other salient points that resonated with me, which I will share here.

A recurring theme seems basic, but it’s critical to remember: We are all human. While we live in a society that strives for perfection, none of us ever will be, and we share many of these imperfections. One such imperfection in our culture is that we are largely death-denying. We would rather do just about anything than contemplate our own mortality. This happens daily. It becomes routine. Therefore, when someone shares difficult news or negative thoughts, our immediate response is too often, “Oh don’t talk like that” or “think positive…it will get better!” As Byock notes, perhaps offhand comments from people could be best viewed as, “an invitation to listen” (15). That is, if someone shares difficult information, help explore the thoughts with something like, “tell me more about that.” There is no telling the depth of what people will share when given a chance.

Another imperfection we share is that, “as we grow up and age, each of us is emotionally scarred to some extent” (39). As part of the human condition, we will love, those we love we will hurt, and they will hurt us. All of this may initially be unintentional, but the scars can be long-lasting. Some of those cicatrices will be more readily recognizable in some people, just as it will be easier for some to share about their difficult past. In others, we may have to be discerning. “People who are nasty, mean-spirited, or greedy are often acting out their own pain” (59). Putting this another way, remember that we are all a product of our past experiences. I find that keeping this at the forefront of my mind during those “difficult patient” encounters can help get to the heart of many issues.

One concept that was entirely new to me was that of “emotional economics.” Byock shares a full chapter on this relating to forgiveness, and it is important to highlight. Consider the emotional scars mentioned previously. The longer those sit unattended to, they accrue “years of compounded emotional pain” (63). I love the analogy of using forgiveness as “a onetime cost” that can help repair all those years of hurt. This can obviously be difficult depending on what the initial insult was, and to some maybe even seem impossible. But, as is pointed out in the book, forgiveness is not absolution. Granting forgiveness to someone does not mean forget and move on. But forgiveness is a huge step toward healing. Refusing to forgive is also a decision to remain in “emotional debt.” If I think about this when talking with someone who may not have long to live, it seems like it could be extremely helpful. Encouraging family members to say “I forgive you” before a loved one dies could be helpful for the days, months, or years that the person granting forgiveness still has left to live.

I regularly hear from patients a phrase that Byock tackles head-on: “I don’t want to be a burden.” Basically, that’s not a thing. Because you are human, and because you are loved by other humans, you will be a burden. Being human will mean at some point things won't go according to plan, your body will fail, and others will have to care for you. The important point is that we can all do our best to minimize this burden on our loved ones by accepting when it is our time to be cared for by others. I have witnessed this become an extremely difficult task for people, especially when it feels like a loss of identity for that individual. Here again, patience and listening will be crucial to coming to a common ground.

Perhaps some of that identity can be maintained by practicing “authentic loving care” as described on page 158. I was struck as this was described as a process that “involves touching people tenderly.” It may seem natural and reflexive to some, but I assure you this does not happen with uniform regularity in a hospital setting. And it’s sad. I was lucky to have this modeled to me during my residency, and as I move into an attending physician role I will make it a point to pass that on to my trainees as well. Don’t be afraid to hold a patient’s hand, touch their shoulder, or one of many other things which can help someone experience human interaction. A small gesture can help a patient in a time of great confusion to remember that they are human and that they are loved.

Lastly, I can’t get enough of the following from Byock which describes why many people might choose to work in the field of hospice and palliative medicine. “It is not within my capacity to discern the ultimate meaning of life in the universe. I can only honor the mystery and hope to be of some service to others” (212). If I could go back in time and put that on my medical school resume, I’d bold and underline it because I like it so much, and it’s the very essence of what I want to do for people. What an awesome gift to be able to live in the service of others during their most critical moments. I am confident that after reading this book I will be able to help others enrich their lives, nourish their relationships, and hopefully mend old wounds even if their time may be short. I simply need to help them see The Four Things That Matter Most.

This is the first Pallimed post by Ben Skoch, DO, MBA, a Hospice and Palliative Medicine physician at the University of Kansas Medical Center. Outside of Family and Palliative Medicine, he enjoys most sports, black coffee, and most especially spending time with his wife and two adorable children.

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