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Death and the Medical Model

A few months ago, I attended a conference in Denver on end-of-life issues and the medical paradigm.  The speaker was Ira Byock, a medical doctor who focuses on hospice care.  Dr. Byock has been adamant about shifting the paradigm at the end of life from a medical one to a more inclusive model (and he's a doctor! wonderful). 

At the beginning of the conference, all of the participants (and most of us were hospice employees) were asked to write about a death that we attended that "went well."  We all, of course, had different ideas of what "well" meant, but one thing was shared--these experiences had left indelible imprints on our hearts.  Some of us shared our stories, and the environment in the room became tangibly warmer.  This was the way we started our conference. 

Similarly, what Dr. Byock argued for in hospice care was more attention to the non-medical pieces of the care: a person's desire to be "delivered from anonymity" at the time of death, his/her desire to heal unresolved conflicts, to share stories, to explore the meaning of life and death ... the list could go on indefinitely. 

The medical model is brilliant for what it can offer, but it is very problem-based.  Death, however, is not a problem that needs to be fixed.  It is a process that is just as life-based as birth, or marriage, or any other sacred time.  Along these lines, the Chinese character for crisis is translated as a hybrid of two words: danger and opportunity.  During a time of crisis, we are challenged at our cores to look at what we consider to be important.  This, at the time of death, is far more important than focusing on medications and feeding tubes (though both are often very important, too!).  When we lose everything we think of as "me," we learn the most about what it is to be alive.  The dying process, then, can often be the pinnacle of living.

Victor Frankyl, a philosopher/author who suffered for years at a concentration camp during the second World War, has said that as humans our deepest pain does not come from our physicality, but from meaninglessness.  As human beings, it is our "neurological imperative" (from Byock) to make meaning.  As hospice employees, we need to be deeply aware of this need, for both our patients and their families/friends. 

Furthermore, we need to begin to see ourselves in our patients.  Part of my frustration with the hospice work I have done has been the duality I've seen between "the living employee" and "the dying patient."  It's as if we think we are standing on the balcony of a beautiful skyscraper, calmly watching the chaos and pain below.  The gossip and judgment that can happen from that balcony is shocking and purely based on our own fear.  We are not only going to have to be "down there" in the chaos and pain ourselves--we already are.  In this sense, then, I feel that we need to fully acknowledge our own mortality if we are to be of any benefit to those who are "dying" (and aren't we all?).

Byock had some wonderful suggestions about how we could bring our own vulnerability to the table when it comes to working with our patients.  For one, we need to contemplate what this culture considers to be "healthy."  Sexy abs and a good diet do not equal health.  I have met many a dying person who I've considered to be far healthier than any athlete out there.  These are people who have surrendered into themselves with grace, humility, and a penetrating sense of humor.  Health, from this perspective, involves looking deeply into our humanness and accepting all that we see.

Another suggestion Byock offered was for us to consider the most important things we can/do say to one another in our lives.  Do we have unresolved conflicts running rampant in our lives?  How often are we resentful or unforgiving?  He offered these four statements as the most inclusive, heart-felt ways of healing our relationships:

(1) Please forgive me. 

(2)  I forgive you. 

(3)  Thank you. 

(4) I love you.

I am not a fan of formulas when it comes to relating with other people, but I have to admit that I cant think of anything that's missing from this picture.  If we can begin to look at every moment of our lives as an opportunity for this level of healing and gratitude, then we can bring forth that level of love into our work. 

Of course, doctors can offer their medical work from this place--but it has to come from the heart, and not solely from the "fix-it-up" mental chatter we have going on upstairs.  To me, the paradigm shift from problem-focus into heart-focus needs to happen not only in hospice care, but in every moment of our lives.

After all, what else is there to do?  (Please, answer me if you can!)


  • Donald 5 years ago

    Love it. Did Iya give a source for the little questions?

  • Hollie 5 years ago

    It's from one of his books--the most recent one. I forget the name but you could look him up =)

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