Reprinted with permission from David Solie.
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 can bring comfort and control to the dying. I the end, it’s all about who’s directing the conversation.
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.
The former 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, the latter intention 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 a 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 to pick up the thread and go with it. The question is how?
Use open-ended questions.
We create conversational “on-ramps” with open-ended questions. These prompts signal our intentions to find out about what’s important to your loved one today. Here are three open-ended prompts that help start the conversation:
- Tell me.
Example: “Tell me about your day.”
Example: “What’s going on today?”
Example: “How are you doing?”
It is important to have your body language as receptive as your words because 90% 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 speaker that you hear them and, just as importantly, you get it. There are three effective ways to do this:
- Play back what was just said.
Examples: “Things have been difficult, but today it seems better.”
“I’m sorry your nausea is ruining your appetite.”
- Paraphrase the essence of what you heard.
Examples: “It sounds like you’ve had a rough few days.”
“You must really miss your cat.”
- Reflect back the feeling behind what was said.
Examples: “It sounds like you really miss your grandchildren.”
“It must be exhausting to have so many medical tests and procedures.”
Avoid interjecting new questions into the conversational flow. They can quickly shut it down. Instead, let conversational threads run their course, including segues into new topics and periods of silence.
In these conversations, feelings can run high and need to be both expressed and accepted. If you’re worried that your expression of grief will be off-putting, give your feelings a personal context. Here are two examples: “This is hard for me” or “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 their legacy.
Stories about the dying person’s life provide invaluable comfort. Legacy prompts declare: “You mean a lot to me” and “You made a difference,” but, especially, “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 conversations you’ve been granted, come what may.
David Solie is the author of Caregiver Mind Maps, which helps caregivers for older adults manage obligations, timing, and communication.