Making Plans For The Last Chapter Of Life

Those close to the late Sen. Edward Kennedy said he spoke of having a "good ending" for himself. Dr. Sherwin Nuland of Yale Medical School and Dr. Ira Byock of Dartmouth-Hitchcock Medical Center share how they talk with patients who are facing the ends of their lives.

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NEAL CONAN, host:

This is TALK OF THE NATION. I'm Neal Conan in Washington. Fifteen months ago, when he learned that he had brain cancer, Ted Kennedy knew that his life would probably be measured in months, not years. But in that time, we saw him keep his promise to attend the inauguration of a man he helped elect president, and renew his long battle for health care.

We also heard that he enjoyed time with his family, sailing, watching movies, eating ice cream with his wife. He said he wanted a good ending, and at least from the outside, it seemed like he achieved just that.

Most of us lack Ted Kennedy's resources but faced with the inevitable, we'd all want that good ending. But after hearing that we have six, 12, 18 months to live, how do our actions square with our hopes?

If this is your story, we want to hear from you. Our phone number is 800-989-8255. Email: talk@npr.org. You can also join the conversation on our Web site. That's at npr.org. Click on TALK OF THE NATION.

Later in the program, Charlotte Allen joins us on the Opinion Page to reject what she calls self-righteous social critics like Michael Pollan. But first, Dr. Sherwin Nuland joins us from the studios at Yale. He's a clinical professor of surgery at Yale Medical School and the author of "How We Die," which won the National Book Award in 1994. And Dr. Nuland, always good to have you on the program.

Dr. SHERWIN NULAND (Professor of Surgery, Yale Medical School; Author, "How We Die"): It's a pleasure, Neal. Thank you.

CONAN: And help us move past the hypothetical, if you will. What do people really do when faced with information that they're going to die in a matter of months?

Dr. NULAND: Well, I was struck by your use of the word resources. Ted Kennedy had not just physical and financial resources. He had emotional resources that many of us find ourselves bereft of when we're faced with a diagnosis of cancer. As a matter of fact, it's much more common not to do this thing of dying well than it is to do it well. And it has to do largely with a disease that carries us off, and largely because of the way the medical establishment doesn't deal very well with death.

CONAN: Well, why don't we take those one at a time? The disease that carries us off - in his case, cancer, as in so many other cases where people are told six, 12, 18 months.

Dr. NULAND: Well, there's cancer, and there's cancer. You know, there are about 80 different forms of cancer. Some leave us with a great deal of pain, a great deal of suffering, diarrhea, nausea, vomiting, inability to eat, paralysis, things of this nature.

So sometimes, the very circumstances of the malignancy itself or of the other disease, whether it's heart failure that doesn't allow us to breathe very well at the end, whether it's Alzheimer's that takes away our cognitive sense, whatever - or a stroke that takes away our ability to be mobile, sometimes to speak very well, articulate very well. These are factors that have to be contended with. And it's all very well for us to look at someone like Senator Kennedy, who had a brain tumor that actually - although it was growing all of the time and increasing the area of his brain that was being occupied - did not leave him nearly as disabled as many people during the last, oh, let's say, six months of life.

CONAN: The other part, the medical profession.

Dr. NULAND: The medical part - well, doctors are very complex people. As you well know, young people who go into medicine are used to winning. They're not used to losing. There was a time when the art of dying consisted of letting nature take its course and relieving people of their symptomatology that was painful or difficult, as much as possible.

Today, a diagnosis of cancer becomes a signal to mount the barricades and really begin the fight. And beginning the fight involves radiotherapy, chemotherapy, surgery, who know what else may be involved, all of these modalities in combination. And we have a great tendency to take what might be a peaceful period of time, a peaceful ending, and turn it into a long period of dreadful misery. As I say, we don't like to lose. What I've called the riddle is the exciting challenge of the diagnosis, the exciting challenge of the therapy, and doctors simply don't like to give up.

CONAN: Neither do patients. Presented with the opportunity, many say wait a minute, I've heard of so many cases where people were told you have six months to live and 20 years later, they're saying hello to their grandchildren. That's - people, you know, sometimes refuse to accept these diagnoses, too.

Dr. NULAND: Well, of course. About 30 years ago, 35 years ago, Dr. Elisabeth Kubler-Ross pointed out what she called the five stages of a fatal illness. One is told one has a fatal illness, one immediately goes into denial, and then there are the phases of anger, bargaining, depression, acceptance.

The fact of the matter is that in my own experience, the only one of these that I've ever been able to depend on, after a long experience with people who were dying - primarily of malignancy, because that's the sort of practice I had - is that denial comes up very quickly. And denial takes many forms, and one of the forms is we are all sure that we will be the one person, or one of very few people, who can lick this thing, regardless of what the circumstances are.

So there's really a collusion, in a sense, between the medical attendings, the patient and the patient's family. They're going to fight this thing out to the last.

CONAN: Joining us now is Dr. Ira Byock. He's at the studios of Vermont Public Radio at our member station in Norwich, Vermont. He's director of palliative medicine at the Dartmouth-Hitchcock Medical Center, the author of several books about facing death, most recently "The Four Things That Matter Most." And Dr. Byock, nice to have you with us today.

Dr. IRA BYOCK (Director of Palliative Medicine, Dartmouth-Hitchcock Medical Center; Author): Thanks. Nice to be here.

CONAN: And you also run a Web site called Dying Well, which I assume by the time people get to that Web site, they've accepted the dying part.

Dr. BYOCK: Well, not all of them. I get a lot of email from people who are very much in the fight, as Dr. Nuland described.

CONAN: And…

Dr. BYOCK: I think, you know…

CONAN: Go ahead. I'm sorry.

Dr. BYOCK: Well, I just think it's important to realize that doctors are doing their job and trying to prolong life and cure people whenever possible. The problem is that our health-care system has been noted to be really a disease-care system, and everything keeps pointing you back to the disease and fighting the disease.

You know, people aren't losers when the cancer progresses. They're just people. It turns out that, you know, we're mortal. And at some point, even though we have enormous power to treat cancer and other diseases, you know, people do eventually die.

CONAN: So you think, in a sense, we misrepresent that when we journalists routinely described it as succumbed to a battle - after a long battle with cancer.

Dr. BYOCK: Well, it's unfortunate. I fall into myself. It does feel like a fight. But you know, we're just mortal, and so we have to - I think as physicians and as a health-care system, we have to, you know, walk and chew gum at the same time. We have to fight the disease, but also realize that there are whole human beings and members of families who are living with this illness.

In fact, it can - we can help people die well. In - even some of the circumstances, though, I fully agree with Dr. Nuland that it certainly makes it more complicated. But even some of the circumstances where people are facing illnesses that compromise their communication or sap their strength or make it hard to breathe, I think what we're doing now in palliative care across the country is trying to help people so that it's not as if they're the first person on the planet to ever face a terminal illness.

CONAN: And how do you start that process?

Dr. BYOCK: Well, you know, what I've learned over the years - and it's almost an anthropological observation more than a medical or even psychological observation - is that, you know, dying, first of all, is a part of living. And I've come to see dying as - really as a critical stage in human development.

People - although we're all individual and very - have specific desires and wishes and fears, there is some commonality to the human condition when we know time is short. And we can wonder aloud with people if it wouldn't be of value for them to do certain things. And I think, frankly, Senator Kennedy's example is a good one.

You know, he got his affairs in order. Now, that phrase usually refers to, you know, transferring the titles on the car or the deed or whatever, updating one's will. But it also extends to sort of just tying up loose ends that are related to job-related responsibilities or special projects or social responsibilities. And in your introduction, you mentioned some of the things that Senator Kennedy did along those lines.

CONAN: Yeah, worked with family - met with his family and then tried to - it's a complicated family, too. I think we probably all know a lot about the Kennedy family and some of the things that they had to talk to each other about. And…

Dr. BYOCK: But people also - they also typically value a chance to just say goodbye or, you know, say thank you and goodbye to colleagues and neighbors and acquaintances that they know from their daily or weekly routines, you know, the person who gives you your dry cleaning every once in a while or cuts the lawn or sells you a latte in the mornings, just to say thanks for being in my life. I probably won't be seeing you much, and I really appreciate all you've done for me.

CONAN: We're talking about - I'm sorry. I just wanted to say we're talking about dying well with Dr. Ira Byock and Dr. Sherwin Nuland. 800-989-8255. Email us: talk@npr.org. And let's get Renee on the line, Renee with us from Portland in Oregon.

RENEE (Caller): Hi, Neal. Thank you so much for having me, and thank you for doing this topic. I'm so glad you guys are doing this. My husband died seven years ago from cancer. He had cancer of the larynx and also of the lungs. And when we went got our - we went through many stages with the cancer, but when we finally got the terminal diagnosis, they gave him about three months, and that was pretty much exactly how much time we had. And we got our diagnosis in July, and he passed away in October.

So one of the things that was important to - kind of became important to him was all the little, small things in life, and one of those was enjoying the last baseball season on TV. The baseball schedule kind of became what we revolved the medication schedules and the food schedules around.

One of the other things I wanted to say was, you guys were just talking about saying goodbye and you know, one of the things that surprised me as we went through this was I really thought that we'd have that moment that you see in movies, with the person in the bed and the other person sitting beside them, and they have this long talk about, you know, their memories and all the things that they want to say to each other. And when I - we had a moment where I thought, okay, this is that moment. And I started to say hey, babe, I just wanted to tell you - and he couldn't speak anymore because he'd had his larynx removed in all of the - during the surgeries. And so he couldn't speak anymore, but I could read his lips, and he could write to me on his pad.

And so I started to say, you know, babe, I just wanted to tell you, and he put his hand up in a stop motion and shook his head. And he mouthed to me: No, I can't do that. It will break me. And so we couldn't have that conversation.

CONAN: Renee, thank you so much for that story. We're going to talk more about that when we come back after a short break. Stay with us. I'm Neal Conan. You're listening to TALK OF THE NATION from NPR News.

(Soundbite of music)

CONAN: This is TALK OF THE NATION. I'm Neal Conan in Washington. And we got this email from Leanne(ph) in Santa Cruz, California. My beautiful, 43-year-old friend died in June from a very aggressive, rare cancer. She was dead one year after diagnosis.

She spent the first 11 months fighting like hell, and the last month sowing seeds of love and telling everyone what she wanted them to know and remember. She was clear, honest and amazingly brave during this time. She was concerned about those of us who were being left, especially her two small children. She was also deeply funny and left us a legacy of love and laughter, and a blueprint of how to die with dignity.

Well, today we're talking about what happens after the diagnosis. Once we hear that we have months to live, how do our actions square with our hopes? If this is your story, give us a call: 800-989-8255. Email us: talk@npr.org. You can also join the conversation on our Web site. That's at npr.org. Click on TALK OF THE NATION.

We're talking with Dr. Sherwin Nuland, author of "How We Die" and most recently, "The Soul of Medicine," clinical professor of surgery at Yale; and Dr. Ira Byock, director of palliative medicine at Dartmouth-Hitchcock Medical Center. His books include "The Four Things That Matter Most." And Dr. Nuland, I'd be interested to hear - that call that we had just before the break there…

Dr. NULAND: Yes. Renee described a very interesting phenomenon that I think all of us have observed, a patient expressing the need, the desire, to quote, be myself until the very end of my life, in spite of the pain and in spite of the disability.

In the case of Renee's husband, all of the difficulty with speaking and with respiration, he wanted to see the baseball game because it was part of what he was. It was part of what he enjoyed. It was part of his surrounding. He obviously had a need to express his love to those around him. One of the problems, of course, is we often unfortunately, regrettably, wait too long.

I think one of the most important things that we can express to someone we love who is about to leave this earth is the sense, specifically, of what his or her life has meant to us. We feel obligated, of course, to relieve symptomatology, basically, make a promise to people that we will make them as comfortable as possible at the very end. We make a promise to people that we will not let them die alone, but we must also do this other thing.

A life is a very, very long process for most of us, and as some wise man said not too long ago, when you look at a gravestone, it's the dash between the two years that really count. Here's what you did for me. Here's what you made of my life because of your life. And if we can get those thoughts across, there's a sense not of complete tranquility, necessarily, but of a certain amount of satisfaction with what one has done and how one has passed one's years.

CONAN: Dr. Byock, perhaps the time might be better spent reading St. Augustine - or Nietzsche, for that matter - but checking out the ball game is important, too.

Dr. BYOCK: Absolutely. It can be the most important thing. I think that people - when I counsel people, I - once I have a therapeutic rapport with them, I ask them if there would be important things left undone or unsaid to other people in their life if they were, heaven forbid, to die suddenly today - as any of us might, whether that's because of their illness or, you know, if they got hit by the proverbial truck.

And that's an interesting way of beginning to frame what we call the work of life completion. You know, what would be left undone? Beyond the practicalities of business and all that, there are - people are what matter most to other people - so, you know, helping people to survey their most important relationships and to sort of just say the things that they feel need to be said.

You don't have to say goodbye. And I was struck that Renee's husband couldn't say that. But if you've said the other things, the please forgive me's and I forgive you's and thank you, and I love you's particularly, then it matters less whether you've said goodbye. Because, again, there's this sense that there's nothing left - critically important left unsaid.

CONAN: Say it out loud. Don't hesitate, either.

Dr. BYOCK: This is a time when stating the obvious is really of value. You know, say it clearly and here, being repetitious is probably a virtue when it comes to saying thank you and I love you, certainly.

When there's nothing left unsaid critically important, it's very interesting that when people who love one another are together, there is this sort of natural sense of celebration that kind of creeps into the time together, because what else is there to say? And so whether it's a ball game or sitting on the porch watching a rainstorm or the sunset or taking a drive or whatever it is, there is this very precious sense of, this is important. This really matters.

And again, I think you saw that in Ted Kennedy's last months as well. I was struck that many commentators this weekend talked about, you know, his celebration lap of this last year.

CONAN: Let's get another caller on the line. Let's go to Skye(ph), Skye with us from San Antonio.

SKYE (Caller): Hi. In - just before New Year's in 2006, my fiance was diagnosed with a very advanced, very aggressive form of cancer and was told from the beginning that he was probably terminal. And he chose to go through their entire treatment protocol, which we personally always chose not to frame in terms of a fight. You know, we just called it his journey, and I always say now that he did a very courageous journey with cancer.

He went through an extremely difficult chemo and radiation protocol and then a very difficult surgery, and then it metastasized anyway. But since the beginning, they told him that he was probably terminal. What was miraculous about his journey was that all of his personal restrictions, all the overly held strong views that he would fight with people about and the prejudices that he projected on the world, he dropped all of that immediately because he said, he goes, what have I been doing? This is insane. This means nothing. And for our entire relationship - we were together for almost eight years before he died. He - in seven years, he probably said I love you five times. He just wasn't able to articulate that. Every action he did showed that, but in the end, he became like me. We said I love you 25 times a day. And he just reveled, and he - I remember one time he looked at me, and he said: God, it's so simple to be so happy.

(Soundbite of laughter)

SKYE: And you know, when he talks - when the physician just talked about - you know, that is where the real healing comes, you know. And I've seen many people go through terminal journeys. And what I tell others when they're faced with that is, I say, you know, healing has nothing to do with what happens to the body. It's what happens to the being within that journey because, you know, as Colin used to say: None of us gets out alive. You know, we're all going to go.

But when you're faced with that, like, wow, it's coming up, and I know it's coming up, it's how you approach that. And he spent so much time with his brother and his niece and nephew, and made calls to family members that were out of state and just, you know, his true heart came alive.

CONAN: It sounds like almost a state of grace.

SKY: It was. It was a phenomenon. I was so privileged. I took care of him until the last 36 hours of his life, and I was just so grateful to watch him have that transformation and to be present for it.

CONAN: Skye, thanks very much for the call, and I'm sorry for your loss.

SKYE: Thank you.

CONAN: Bye-bye. Here's an email we got from Chip in Owings Mills in Maryland. Maybe I'm misreading your point here, but you sound like the fighting or the denial or the refusal to accept death is somewhat terrible. I consider it a positive facet of the human spirit.

When my mother was given her final diagnosis, she accepted it almost gracefully, but until then, she treated her disease as if it were the enemy. I hope I have that courage when the time comes. Dr. Nuland?

Dr. NULAND: Well, I'd like to address a couple of the comments that have been made. Virtually everything that Dr. Byock and I have said is based on the premise that there is no denial - that patients, families, even the doctor are totally honest with each other, sometimes to the sort of - well, I'll call it a merciful bluntness. That's the kind of thing you might say, that if people are able to face the likelihood, the probability, that they will not survive beyond a period of time, the kinds of things that you've been hearing in the last 20 minutes can happen.

There's a phenomenon that I call the better-angels-of-our-nature phenomenon, in which someone who recognizes that there is no further point to fighting this - or even if he is fighting it actively, but who accepts it, finally comes to that point of acceptance, that person becomes what he is at his very best, what he has been at his very best. Love means more to that person. The associations around him or her mean more, and the trivia of our lives and the denial of our lives disappears, just as the denial of the cancer disappears.

One of our problems is that built into the psyche of human beings is the phenomenon of denial, the fact of denial. Some people, after you tell them that they have a malignancy - and I'm sure Dr. Byock has had this experience - will come back for a second visit, when you want to outline the plan for treatment, and deny that they have actually been told they have a malignancy. That's how strong it can be, and it can carry right through to the end, even in the very face of death.

CONAN: Let's see if we can get another caller in. This is Bruce, Bruce with us from Coral Springs in Florida.

BRUCE (Caller): Hi. Good afternoon.

CONAN: Good afternoon, Bruce.

BRUCE: I probably wouldn't have paid too much attention to your program other than the fact in February of this year, I was diagnosed with advanced pancreatic cancer. The statistics are not pretty good. There's a 5 percent survival rate over a five-year period. But you know, it's one of those things that life throws a curve ball and you realize that you just have to face it. It's not an easy task but with a loving family, with friends and support, hey, it's one of those things.

CONAN: And what have you been doing these past months, Bruce?

BRUCE: I work with a charity here in Fort Lauderdale, the Pantry of Broward. I've been going to work as best I can, at least four or five hours a day. And my boys, who are over at university - and they've been back, and just spending time with family and friends.

CONAN: And that sounds like a really good idea. I have some experience of pancreatic cancer. My family and I know how difficult it can be. It's not easy.

BRUCE: It's not easy, Neal. But by the same token, life is a journey. As one of your speakers said, you know, death is a part of the cycle of life. And energy is neither created nor destroyed; we just go somewhere else. And it's not so much perhaps how long you've lived, it's how you've lived it.

CONAN: And the last part is part of that living, too.

BRUCE: Very much so. You know, it's - you forget about all the superfluous stuff, you know, the man toys, the car, the house and all that stuff. And it gets back to things that are really important, which is the family.

CONAN: Bruce, we wish you the best of luck.

BRUCE: Thank you. And I hopefully - I'll call you next year.

CONAN: Absolutely. We'll count on it, Bruce. Bye-bye.

Dr. Byock, I wonder, Bruce sounds like he's doing the right thing. There are people, though, who, as Dr. Nuland was saying, have difficulty accepting it.

Dr. BYOCK: There sure are. None of this is easy, you know? I want to be clear for our listeners, that while we're talking about things that are of value - and some of the callers are illuminating that there really is a special value to this time of life, or can be - this is really hard. Between symptoms and just lack of energy and all of the financial and just social complications of having a serious illness, this is really hard. But in fact, it is a time of life and, you know, denial can be really healthy, frankly, at the beginning when you're shocked by this bad diagnosis. Sometimes it can almost - denial can be sort of an emotional spigot so that you don't have to, you know, incorporate all that bad news and the implications of it all at once.

But at some point, you really have to both fight the disease, if that's - if there's a fight to be had there on one hand, but also live with it, day to day trying to, you know, wrest as much enjoyment and joy out of the day as possible, but also planning for the future. Somebody once said dying doesn't cause suffering. Resistance to dying causes suffering.

CONAN: We're talking with Dr. Ira Byock and with Dr. Sherwin Nuland about dying well.

You're listening to TALK OF THE NATION from NPR News.

Dr. Byock, I didn't mean to cut you off.

Dr. BYOCK: Well, if all we do is continue to fight and deny that the disease is progressing with something like cancer or ALS, you know, Lou Gehrig's disease…

CONAN: Mm-hmm.

Dr. BYOCK: …or even severe congestive heart failure, then what ends up happening is things that most people don't want. For one thing, you spend most of your time seeing doctors, and often in hospitals. And for another, you just don't have the setting and the opportunity and the energy to invest in the personal aspects of life.

Dying is fundamentally not medical. It's personal. But in our disease-based system, it's really easy for doctors and nurses and health systems, through no ill intention, to sort of medicalize the last part of our lives.

CONAN: Now, let's go to Gary, Gary with us from Philadelphia.

GARY (Caller): Thank you for taking my call.

CONAN: Sure.

GARY: My wife was diagnosed with small cell lung cancer at the age of 45, and we lost her in the year 2004. The internal medicine doctor, the one that did all the pretesting and then dropped the bomb on us at his office, he took me aside, said she had nine months. So if you have to make plans, such as funeral plots, that kind of thing, go ahead. He told her not to go looking up your disease on the computer, because everybody's disease is handled differently. So you're just going to get - even though it's stage four, you're just going to get a synopsis of what you should be looking forward to, and everybody is different.

CONAN: Mm-hmm.

GARY: So we're walking out of the doctor's office, and she apologized to me, firstly. She said, I'm sorry. I brought this on myself. And now, you and Leah, my daughter, have to suffer for this - which was the thing in our religion that is usually done when someone inflicts, like smoking on himself.

CONAN: Is that what she did?

GARY: That's what she did. She smoked. But - and she never touched another cigarette again after she walked out of the doctor's office, of course. She said, that's the easiest way to quit smoking. But over the nine months - and again, she - as soon as she got home, she ran on the computer and looked it up and said, I have nine months. And I said to her, I said, if you had nine months, then I want sex every day. And she says, I'd rather go now.

(Soundbite of laughter)

GARY: I mean - and that's how we - well, that's how we went through the 42 months that Fox Chase Cancer Center gave her. They went at her very aggressively, because of the fact of her age. She had lung radiation twice a day, 9 in the morning and 4 at night. And I used to say I didn't mind taking her back and forth because they had great coffee, I told her. And we decided to have as much fun in our lives in the last few years as we could. You know, in that 42 months, I would say 35 were good months, you know, when she was up and about and doing things. We even had a - made a trip to Hawaii.

We - I never missed an appointment with her. She was having chemo almost every day for the first month and a half - radiation only the first 15 days, and they can't do it anymore. She had to have an operation to dilate her esophagus because she couldn't swallow. She had finally…

CONAN: But it also sounds like, Gary, like you did have fun.

GARY: We did have fun. We did have fun. Even in between, like, the rides up to Fox Chase from South Philly up to Northeast Philly, you know, sometimes we'd get in arguments over traffic or whatever. And I said, you know what, Cass(ph), I'll kill you. The hell with the cancer.

(Soundbite of laughter)

GARY: You know? And - but she did also, she - and I had a friend that…

CONAN: Gary, I'm afraid we have to go, Gary, but…

GARY: I have a dentist appointment for her, and my friend said, why would you take her to the dentist? That's she's going to die. I said, you don't stop doing things like that. You…

CONAN: Gary, thank you very much for the call. We appreciate it.

This is TALK OF THE NATION from NPR News.

(Soundbite of music)

CONAN: This is TALK OF THE NATION. I'm Neal Conan in Washington.

In just a couple of minutes, we'll talk with Charlotte Allen on the Opinion Page this week. Her piece is called "Keep Your Self-Righteous Fingers Off My Processed Food."

Well, we wanted to wrap up our conversation with Dr. Sherwin Nuland and Ira Byock about dying well, in part because we wanted to take this call with Will. And Will is on the line with us from Berkeley, California.

WILL (Caller): Hey, Neal. Hey, guests. Thanks for taking my call.

CONAN: Sure.

WILL: A couple of years ago, I was diagnosed with prostate cancer. I'm 50 - I was a 52 then. I'm 54 now. Everybody says, hey, don't worry about it. You're going to be fine. Prostate cancer is a breeze. But just recently, they said, you've really got about two or three years to go before it metastasizes and mortality takes over. So I've been dealing with all the issues. And I think I've kind of got a handle on it with regard to, you know, being out of denial and facing it.

Where I'm really having the struggle is getting my friends and family through it, because maximizing the time left means forging stronger, more intimate relations with family and friends.

And, boy, when I tell them about my health situation, it's like using a giant leaf blower on them. They just scatter to the four winds. Can anyone give me any insight into this? I don't know. Is it a phenomenon?

CONAN: Dr. Byock, is this something you've dealt with?

Dr. BYOCK: Sure. People don't want to talk about it. I mean, you know, I don't want to think about it is about the credo of the American culture related to these things. So it's not - I'm not terribly surprised that you're having this experience.

I think, you know, you have to have compassion for them. You're dealing with it but they're, you know, they're afraid. It reminds them of their own mortality, and it reminds them of not wanting to lose you.

There are ways of approaching it. Sometimes I suggest that people simply write letters and say what they want people to know either now or letters that can be opened later when, you know, after you eventually die - letters to your family, especially young children, who may not, you know, want to talk about it or you may feel that they're not ready to have these conversations, but they would want to hear from you years later.

CONAN: And Dr. Nuland, is there any way to tell your family members, hey, this isn't really about you?

Dr. NULAND: Well, the family, of course, is always the one part of this triangle that's left out of things. They do everything they can to support a dying person. They're often told something just a little bit different than what the patient is told. And yet all of the time, there is this entity called the family treated as if the family is a monolith. Every member of that family has different needs and different wants.

And of course, the word family brings up something that I've spoken about often - and I appreciate the opportunity to speak about it now -which is the family physician: who is the oncologist, who is the surgeon, who is the internist - someone probably not very well known by the patient, by the family before this disease took over.

What is needed in this country is the resurrection of the family physician who knows people very, very well, who understands, therefore, what denial means in this particular person, what depression means in this particular person, what acceptance means - and can be an excellent professional guide to helping the family, and the individual who has the disease, from going through the emotional tortures that they so often do. I'd like to ask Will a question if he's still on the line.

CONAN: I think he's still there. Yeah.

Dr. NULAND: On what basis did they change the outlook for you? Had something changed in your blood tests, or had they found something new?

WILL: Well, after surgery, and then a year later after chemo and short-term hormone therapy, my PSA started to rise again…

Dr. NULAND: I see.

WILL: …and there's just no options left. So once it gets to a certain level, they'll start long-term hormone therapy. And then when I become hormone refractive, it'll go metastatic, and that's the game. That's the ball game.

Dr. NULAND: So they had objective evidence that this was returning.

CONAN: Yeah.

WILL: Yes, sir.

CONAN: Will, I'm sure that everybody listening is with you and wishes you the very best.

WILL: Thanks, Neal.

Dr. BYOCK: Neal?

WILL: I sure appreciated the chance to talk.

CONAN: Sure. Thanks for the call. Bye-bye. Dr. Byock, if you could make it quick.

Dr. BYOCK: I just want to say that in centers across the country, here at the Norris Cotton Cancer Center in Dartmouth-Hitchcock Medical Center, as well as others, we're really trying to humanize this experience for patients and their families. And the work that I'm doing in palliative care is really being replicated also around the country.

We are quite intentionally doing assessments of patients with their families, and trying to help walk them through both very aggressive courses of disease-modifying treatments and hopefully, you know, prolonging their life but also, with eyes open, really helping them deal with the emotional, social and spiritual aspects of having a life-limiting illness, and trying to deal with the complexities from -everything from the health system and finances to pain management and other symptom management as well as, you know, the work of life completion.

It's getting a bit better, and we've got a lot of work to do. But in the midst of health-care reform, we often focus on insurance and the finances. I hope people are aware that there's really an assertive movement of trying to humanize our approach to people with serious, life-limiting illness.

CONAN: Dr. Byock, thank you very much for your time today.

Dr. BYOCK: Thank you.

CONAN: Ira Byock joined us from the studios of Vermont Public Radio. He's director of palliative medicine at Dartmouth-Hitchcock Medical Center, author of several books and most recently, "The Four Things That Matter Most."

Dr. Nuland, always good to talk with you.

Dr. NULAND: Thank you, Neal.

CONAN: Sherwin Nuland joined us from Yale University, where he's a clinical professor of surgery, the author of, among other books, "How We Die."

We'll end with this email from Cathy(ph) in Westerville, Ohio, who was diagnosed with stage four uterine cancer in January 2008.

I find that I love the peace I have day to day doing all the things I put off and hurried through in my pre-cancer days. My family and friends have all been super supportive. I wrote my obituary, contacted my funeral director, wrote letters to my dearest friends and families, and I'm going about the task of living each day. I am grateful for everything I do, no matter how mundane. And I know that when it is my time to die, I will have done my best and made the best of my life. I am content.

Coming up, the Opinion Page.

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