Conversations at the End…

We wish it didn’t come to this, but it does. Someone you care about is at the end of their life. No one knows exactly when but everyone is clear about what’s happening. Now comes the hard part, the conversations that occur before they’re gone. What do you say to those who are leaving? How do you avoid stumbling into uninvited pep talks, dismissive assurances, awkward displays of grief, or embarrassing cliches? Maybe you don’t. None of us are really prepared for conversations near the end. Our emotional vulnerability alone leaves us at a loss for the right words. Fortunately, there are ways to reframe this difficult dialogue that bring comfort and control to the dying. In the end, it’s all about who’s directing the conversation.

Reconsider expectations
Initially, we may feel our role in these conversations is to orchestrate meaningful moments. However, the days prove emotionally and physically uneven as are the conversations associated with them. The dying are better served if we simply recognize the conversational thread being offered in the moment and facilitate it.

Set the intentions
How you follow the conversational currents of the dying greatly depends on your intentions. This is not a casual decision because intentions shape your thoughts, words and ultimately behavior. As such, they become deeply woven into the outcome. Even seasoned professionals use intentional scaffolding to anchor and guide their conversations. Here are two intentions that are effective in this setting:

Cure when possible, comfort always
Best possible day, no matter what

Cure when possible, comfort always is taken from the Hippocratic oath. It reminds us that our role is to comfort within the limits of a situation we cannot fix. The comfort we bring includes our acceptance of the way things are as well as our words and gentle silence.

Based on Atul Gwande’s article in the New York Times, best possible day no matter what further reminds us that our role is to be open to what’s possible in the current situation. We can’t unwind reality, but we are free to embellish the moment with whatever can make it better.

Honor the agenda
The psychological agenda of the last phase of life is all about control and legacy, the paradoxical tasks of lasting and leaving. One task requires hyper-vigilance to guard against an unending series of losses that push life out of control. The other task requires a reflective pause, a review of life’s events and an eventual letting go.

Our role is to honor and facilitate the agenda. This is why the kindest control you can offer the dying is the courtesy to let them talk about what they want to talk about. They choose the topic as well as the depth and duration. Our job is pick up the thread and go with it. The question is how?

Use open-end questions
We create conversational on ramps with open-ended questions. These prompts signal our intentions to find out about what’s important today. Here are three open-ended prompts that help start the conversation:

Tell me about your day
What’s going on today?
How are you doing?

It is important to have your body language as receptive as your words because ninety percent of communication is nonverbal. Pull up a chair, relax your shoulders, lean in, and stay connected to the conversation. Be accepting of any topic that arises from the mundane to the profound. Once you identify a thread, follow it with reflective listening.

Use reflective listening
Reflective listening conveys to the person speaking that you hear them and, as important, you get it. There are three effective ways to do this:

Play back what was just said:
Things have been difficult, but today is seems better.
Your nausea is ruining your appetite.

Paraphrase the essence of what you heard:
It sounds like you’ve had a rough few days.
You really miss your cat.

Reflect back the feeling behind what was said:
It sounds like you really miss your grandchildren.
It’s exhausting to have so many medical tests and procedures.

Avoid interjecting new questions into the converational flow. They can quickly shut it down. Instead, let conversational threads run their course including segues into new topics and periods of silence.

Respect emotions
In these conversations, feelings run high and need to be expressed and accepted If you’re worried that your expressions of grief will be off putting, give them a personal context. Here are two examples:

This is hard for me
This means a lot to me

Remember, facilitating conversational threads can be done in many ways including talking, laughing, crying, praying, and sitting. And there are always stories.

Frame the legacy
Stories about the dying person’s life provide invaluable comfort. Introduced with legacy prompts, they declare:

You mean a lot to me
You made a difference
You will be remembered

Here are three examples of legacy prompts:

I’ll never forget…
You have no idea how many times I’ve told the story about…
One of the best moments in my life was when…

Remember, stories beget stories and with each telling comes an opportunity to discover new meaning and connections. Feel free to embellish them with music, pictures and people.

Let it be
Finally, each conversation with the dying stands alone. Don’t predict their meaning. That comes much later. Simply hold the intentions, follow the thread and be thankful for the conversation you’ve been granted, come what may.