Podcast #79 Dr Ira Byock – Palliative Care Physician and Author – The Four Things that Matter Most

Dr Ira Byock – leader in palliative care, advocate for patients, and author – joins me this week. We discuss: What might it mean to “die well”? Why is the nature of serious illness more personal than medical? What  are the “four things that matter most”? What does “forgiveness” mean? How do the phrases he writes about in The Four Things that Matter Most apply to any of us, at any time in our lives? This week’s BLBD conversation really grabbed me, because it is about dying, sure, but it is far more about living… and living with humility and kindness.


Diane Hullet: Hi, I am Diane Hullet and welcome to the Best Life Best Death podcast Today I’ve got a really interesting guest, and I know I say that all the time, but you know, they just always intrigued me, Dr. Ira Bock. Is a leading palliative care physician and author and a public advocate for improving care through the end of life.

He’s been a founder of amazing healthcare systems from Dartmouth to Fresno, California to Missoula, Montana, and he’s been involved in hospice in palliative care since 1978. He’s written three books, at least three books, three that I know of Dying Well, the Four Things That Matter Most and the Best Care Possible.

His most recent book from 2012. Today, he, and I’ll be focusing on the book, the Four Things That Matter Most. It came out in 2004 and then was reissued with a 10th anniversary edition, and I can’t believe this book is 20 years old. It’s so relevant. Enjoy my conversation with Dr. Bak. So welcome Dr. Baek.

Nice to see you. 

Dr. Ira Byock: Nice to see you too. Thanks for having me. Yeah. 

Diane Hullet: So you’ve, you’ve written several different books. Do you wanna just start off by telling us some of those titles? Cuz I think we’re gonna kind of focus on the four things that matter most, but you’ve got 

Dr. Ira Byock: Wonderful. Well, well, sure. So I’ve been a, a doctor in this field since, you know, the late 19 seventies.

And and I, I didn’t plan it that way. My first book is called Dying Well, and I wrote it in 19 95, 96. Looking back at my career at that time and trying to tell the story through my own experience of how I, who thought I was gonna be a rural family doctor in, in the Rockies, that, that was my dream in going to medical school and residency got kind of pulled into caring for people who were facing the end of life.

So, And I, it’s a book of stories. All my books are books of, of stories. Dying Well opens with my dad’s story who my dad, Seymour Bioc was living with pancreatic cancer, which as the story, it’s the first chapter in Dying Well. Is, is is Sigh story. My dad. It opens with me diagnosing him over the phone as he was telling me about, about becoming jaundiced.

And he was in New Jersey where I grew up on the Jersey Shore and I was in Fresno, California doing my family practice residency. And I had this sort of cold sweat when I realized, oh my God, my dad is dying. So it starts with his story, and then it’s a number of stories of people who I met during residency, and then when I was a hospice physician in Missoula, Montana who taught me something about the experience of wellbeing during one’s dying, you know, dying.

Well, the, the, the, I chose the title. To a large extent as a contrast with the phrase Good death, which was and still is sort of used way too often and dying. Well, it’s a jarron, it’s a, it gives you a sense that, that you’re living while you’re dying. But the word well is not just an adverb describing the process.

It’s really more provocative to hear it as an adjective describing a person who is dying. Can somebody die well? Can they be well within themselves? That has been the thread that has ended up captivating me and directing my career. I. And what I’ve written about in several different books now, dying Well is a book of, you know, you know, eight or 10 stories of people I had the privilege of knowing or caring for through the end of life, each of whom illuminated some other aspect of wellbeing.

And then we’ll talk about the four things that matter most, which was my, you know, effort to sort of distill. What I would call the, the work of life completion from a developmental human development frame particularly completing relationships when we can come back to that. And then the, my, my most recent book published now 10 years ago while I was working at Dartmouth in directing the palliative care program at Dartmouth in New Hampshire.

So, Is called the best care possible. And, and it’s about ba basically about highly personalized care for people who are seriously ill. Because the best care possible is what everybody wants. When you or someone you love is seriously ill, you want the best care possible. But what it means may be entirely different from one to for one person than another.

I mean, My dad had pancreatic cancer and he was, you know, was 63 or something when he got, was living with pancreatic cancer. And what was right for him, what was the best care for him might be entirely different than somebody who’s 63 and comes from a different background and has just different idiosyncratic values and preferences and just as a different person because the nature of illness.

Is personal. It’s not just medical. And while that seems so well, sure, duh. You know, in fact, within healthcare and, and frankly within the dominant American culture, we kind of default to assuming that if you’re seriously ill, your experience is somehow medical. Fundamentally medical. And we get it wrong, man.

Everybody gets it wrong. So, so I’ve written about the personal experience of illness and the phenomenon of wellbeing through the end of life. 

Diane Hullet: That’s so powerful. I just wanna underscore that, that, that when you are diagnosed with something, when you discover that you have a disease, and maybe it’s a life limiting disease, that is a personal experience and we wrap it in a medical field and kind of assume that treatments and response and your age and your stage and all that will be somewhat fit in a package when in fact it.

It just doesn’t, and what it means to go through that, well, through that health crisis or through dying is such a personal event. And, and I love the word like it’s a communal event too. You know, borrowing that Barbara Carns, she says Dying is not a medical event. It’s a community event and it impacts the dying person and everyone around them.

Dr. Ira Byock: Yes. So I would say it’s a personal experience. But because. Persons, whole persons are individuals within the context of families, really their households and their communities. For me by understanding that it’s personal, you wrap in the, when one person has a serious influence serious diagnosis, the family, his or her family shares in the illness, right?

And so does his or her community. And I, I go through this. I mean, it’s important to me because as a physician, Who started as a family doc but has, you know went on to practice. Well, I practiced emergency medicine as well cuz when I was doing hospice care, you couldn’t, you couldn’t just be a hospice doctor.

You couldn’t put food on the table at home if, if you were a hospice doctor. But I was a, I was an emergency doc but also as a, as a hospice and palliative care doc, if I can keep in my mind that the. That the patient I’m serving, I’m serving their personal experience. I have enormous value to add, bringing medical technology, the diagnostics and therapeutics to bear.

But it’s always in service of their personal experience. And, and unfortunately, we, we often, particularly doctors, I think tend to, to assume that the personal would be subordinated to the medical. And so do we as patients. And, and by the way, let me hasten to say that that’s entirely appropriate sometimes when, you know, you know, to, to subordinate your personal experience cuz you gotta get medical things done.

But it’s, but it’s not always appropriate. 

Diane Hullet: Right, right. If it’s an emergency room situation and you’ve gotta just get that wound closed or right, deal with that, back that broke or something, you’re gonna just do the technical thing. But so many times it’s the person and the personal experience, 

Dr. Ira Byock: and as illness progresses and medical technology and therapeutics, frankly has less to offer in terms of the physi physiology or living longer.

The, the personal clearly has to take priority to the medical. The medical is there then to support the person. Right. 

Diane Hullet: I think about that term, slow medicine, you know, there’s, mm-hmm. I think this, they call it the slow medicine movement, which is kind of how in your elder years or living with a terminal illness, do you, do you create some slow medicine for yourself?

So that’s a little bit more, I think, supporting the personhood. Yes. So I’m guessing that out of that first book and those early experiences in your career, that those must have been where the themes really developed for the book that, that we’re gonna talk about now, which is this. Sure. Four things that matter most.

And I did, I found it so interesting to realize this was published in 2004 and I had picked up the, you know, 10th anniversary edition. I mean, it’s almost 20 years old and so relevant. Still don’t you feel, 

Dr. Ira Byock: thanks. It, it, yeah. Be because firstly, I, I didn’t invent any of this stuff. Of course, this stuff is embedded in, in wisdom traditions that go back forever.

There’s a there’s a, a, a Hawaiian or old Hawaiian tradition that that uses. These four things that I didn’t know about when I, I wrote this book. I learned this from, from the, this wisdom from you know, social workers and nurses back in Fresno, California, in the nine, in the 19 seventies. But the four things, just so we let our, your listeners know are aren’t things at all there.

There’re four sentences, 11 words. Please forgive me. I forgive you. Thank you. I love you. Please forgive me, and I forgive you because there’s not been a perfect relationship on the planet in the history of our species. Even the most close and loving relationships tend to be marked by some history of hurt, feelings, misunderstandings, fallouts, but sometimes real transgressions and, and, and disloyal and betrayals and all of that stuff that happens because life is messy.

Please forgive me. I forgive you. Thank you. And I love you is so often like stating the obvious, but it’s so important, particularly in, in the circumstances of people facing the end of their lives to, to say it out loud. And I, I wrote this and, and frankly, this does go back to my earliest experience and in dying.

Well, I talk about saying the five things before you die. Please forgive me. I forgive you. Thank you. I love you. Goodbye. And I, and that would be part of so many lectures I gave and things I taught to my colleagues and medical students and we, and discussions at hospice team meetings, but also at conferences and all of blah, blah, blah, blah.

All this stuff that I was doing as a, as a much younger hospice doc, trying to help build the field and make change the change healthcare at least, and maybe our culture. And not uncommonly, you know, somebody would come up to me after, let’s say a, a lecture and say, you know, I loved the, that those five things are great, but you know, Dr.

Bak, you don’t have to be dying to say those things. Right. And I of course say ab absolutely. You know, thank you very much. You’re absolutely right. And I’d go on and, and, and I’m somewhat embarrassed to say it took a few years and I finally started to realize everybody who says that to me has a story. I really want to collect those stories.

So I started pretty deliberately saying, could, would you like to talk? I’d love to talk to you and just get your story or Yeah, tell me more about that. Tell me more. Right. So so I started to collect stories and, and and and then after a time I, you know, I had this sense that. We weren’t gonna change healthcare.

Not every seriously ill person was going to probably have a doctor or a hospice team, or even as it was developing a palliative care team to guide them in these normal tasks of completing relationships, right? Honoring and celebrating relationships Really. Because it’s so, cuz it is what matters to people, you know?

And I decided I have to, I have to teach the public. It’s, you know, I have to talk to the public directly. I have to get, I have to have a dialogue with the culture. Because this one, this one we can do for ourselves. This is not like insight therapy or, or something that has how can I say it? Counseling that has risks, right?

You don’t need 

Diane Hullet: an expert. You don’t need expertise in this to be guided in this. This is really simple. 

Dr. Ira Byock: This is pretty simple. Asking for an offering forgiveness. Expressing gratitude and love are about the least toxic, most positive things people can do. Right. 

Diane Hullet: And I love that by writing the book and saying, let’s put this more out to the public.

You’re, you were also saying, let’s do this younger. Let’s not wait till the dying moment. Let’s, as you said, this doesn’t, Hey doctor Dr. Bak, this doesn’t have to be for dying. This can be. At any occasion, at any conversation, at any moment, there can be these sudden openings of gratitude that can really alter 

Dr. Ira Byock: relationships.

Yes. And forgiveness. 

Diane Hullet: You say in the book, you say you know, forgiveness is maybe the least understood or the most misunderstood. Yes. Say, say more about forgiveness. 

Dr. Ira Byock: Well, we think some, somehow forgiveness is about redemption or or absolving somebody who harmed you of their responsibility, right?

And, and that’s just nonsense. And there’s this phrase, forgive and forget, which is the stupidest phrase, or, or a little nostrom in the English language. I mean, for one thing, forgiveness requires remembering. Right. If you can’t remember, that’s amnesia. That’s not forgiveness. Right? So forgiveness means accepting that the past cannot be changed, right?

The forgiveness means giving up all hope of a better past, right? But acknowledging that the past need not control your future. It’s a, it’s a letting go of things, but you know, if somebody harms you, if you’re, if you’re in business and somebody buys something on, on loan and never pays you back, right?

You can forgive the debt. You don’t have to let it accrue interest. You can take the loss one time, right? It doesn’t mean that you’re gonna do it again, but you don’t have to walk around with that on your books, right? That emotional for forgiveness is, is, is similar. 

Diane Hullet: You don’t have to walk around with it on your books.

Dr. Ira Byock: Right. Or carrying that burden on your shoulder. Right. You can let it go and, and it’s just a happier thing and, and express it. People say, well, Dr. Bak, well, you know, as a, as a hospice and palliative care doc and having cared for so many people who are facing the end of life, what’s that taught you about?

How’s that changed your life? You know, I’d love to tell you that’s, that’s a good imitation. I like that. I, I wish I could say I never screw up anymore. I never, I never say the wrong thing. I never snap at somebody I love, like my dear wife or, you know, but that would be a lie, right? What it, what it has done, what I’ve learned is to apologize far earlier and more authentically.

And in a, in apologizing, what I, how I understand apologizing is it is standing in front of somebody who you care about and. Acknowledging. It’s almost like standing naked in front of them. They can see all of your imperfections, all of your warts, and say, will you still accept me? I am so embarrassed about I’m, I’m ashamed of myself having done that, even if it’s a small infraction, there’s a little touch of, well, I’m really ashamed of myself.

Right. Will you still take me? Can we, and it’s a, it, it basically is a statement that this relationship means more to me than how embarrassed I feel right now. Right, right. It works out well usually if it, if that is accepted. And ironically though, I’m not gonna say this is a strategy for strengthening relationships.

Ironically, in my experience, relationships tend to get stronger after you’ve, you know, apologized in an authentic way to somebody. 

Diane Hullet: There’s a softening, right? And then that softening is kind of our vulnerability. And then our vulnerability is our connection, I think. Exactly. I love, I love you. Say that one interviewer said to you.

Okay, Dr. Baek, I should do my interviewer voice, Dr. Baek. You say the none. You know the kernel of the book in the first paragraph, these 11 words. Why write a whole book about it? 

Dr. Ira Byock: And I, right. He actually said, why would anybody buy this book? And I, and this was on my satellite book tour, you know, as I was actually trying to sell books during those two weeks.

And I, and I, you know, my first thought was a good point. And I 

Diane Hullet: read that, I read that in the book cover. I read it inside Flap, what do I need to buy this 

Dr. Ira Byock: for? Exactly. But But the real answer is because it all sounds so preposterous the unless you read the stories, and I, and since you read the book, you know, I chose, I choose some really tough stories unless, I mean, the stories carried.

The lessons that even in pretty seriously fractured relationships and when real transgressions have happened or anger is entirely legitimate healing is possible. If I were to say healing is possible without that, it sounds like some sort of pop psychology or woo woo. You know and, and that’s not where I’m coming from.


Diane Hullet: right. There’s there like, there’s a beautiful one I remember kind of early in the book where, where there’s a couple and the man is very angry at the woman and she’s dying and he says, well, you know, I. I, I can say maybe for, please forgive me and I forgive you and maybe thank you, but I am not gonna say I love you.

I’m too angry. There’s been too much hurt through the years and I won’t say it. And the person who’s working with him, they end up talking about, well, maybe when you’re in bed at night, maybe just whisper. I love you to her back. And see what happens. And he does that. He lies in bed one night and he whispers to her back, I love you.

And then he feels that connection that he had with his wife in all their early years together and all the long, long years they’ve been together and the transgressions kind of disappear and he leans over and he actually says, I love you. And she turns to him and responds in kind and says, you know, you’ve been my rock.

And I’m so grateful and. It, it completely alters their relationship and creates what I would call a dying well situation, right? Where this, this almost impossible gratitude and connection that neither of them thought were possible actually arises between them. 

Dr. Ira Byock: If, if it didn’t happen, you wouldn’t believe it.

Right. Exactly. 

Diane Hullet: Exactly. It’d be like a 

Dr. Ira Byock: bad fiction book. No, that, I’m sorry. You know, that will, that’ll take months or years on the couch in therapy to, to work through this one. But the fact is, and this is something about serious illness, particularly though it’s not restricted to serious illness, but, but somehow, when one or the other person.

Is living with a life-threatening condition or knows that time is short, there is this sort of catalytic energy or opportunity to amend, tend relationships. It’s quite, it’s quite remarkable. You know, again, I started as a family doc. That was my training, and I, I, I imprinted on, on human developmental theory and I, I think, What, what I’ve been doing through my career is trying to bring some definition to and teach this notion of human development through the end of life.

That serious illness and knowing that you’re in a stage of life called dying is an entirely normal stage of human life, and it comes with its own serious challenges and risks of suffering. Absolutely. And it also comes with, with particular developmental tasks and opportunities. 

Diane Hullet: And say more about those.

You talked about completion and especially completion of relationships. 

Dr. Ira Byock: So there’s completion of your worldly affairs. There’s just doing the practicalities of, of closing. You know, bank accounts or giving your passwords to people you love, including not only your, your financial stuff, but your Facebook account or, you know, so that they can close it doing you know, making sure they don’t have to go through probate by changing, you know, the, your will or the title of the home or your, or, you know, your fiduciary will, your, your financial will.

There’s turning over projects that mean a lot to you to to others. There’s again, making sure there’s nothing left unsaid, critically important, left unsaid between you and, and people you you love. Think there’s also Something very healthy in deliberately celebrating life and relationships.

If you have the time, if you are, if your, you know, medical condition allows you the time and energy to do so, there is something life affirming. And about cel having a celebration, letting people celebrate you and, and you know, maybe even roast you, you know, at, at a party. But, but also, you know, having it be a dialogue and letting them know how much you love them and, and, and just reminiscing together.

There is, I think there’s a healthy defiance in. In our relationship to the force majeure to death that says even death can’t take this from us. We matter, right? This relationship is important, this community is important, this family is important. And damn it, death is not gonna take, take that from us.

We’re gonna celebrate in the face of it all. 

Diane Hullet: Beautiful. I think that that takes a huge amount of courage because you’re not, because you’re not talking about denial. You’re talking about in the face of still being willing to claim our humanity and our community and our relationships and our loved ones as vastly important to us.


Dr. Ira Byock: right. I’m, I, so, I, I really do think these are developmentally important opportunities that we have in the, in the difficult, inherently difficult, unwanted. Time of life we call dying. I, again, I’m not trying to put, you know, a lipstick on this pig or, or look at it through rose-colored glasses to change me.

Metaphors it, you know, dying sucks, right? You can quote me, but it doesn’t only suck. Oh, I’m gonna 

Diane Hullet: quote you on that.

Yeah. I love, there was a part in the book when you talked about tending that I was gonna read. That was so great. You say Because of my work with patients of many ages, backgrounds, and life circumstances, I know that this kind of healing is not just a matter of luck. And I think that’s so important as a doctor, I cannot heal relationships between other people any more than I can, will the grass to grow.

I can prepare them for healing, plant some seeds, keep careful, watch and nurture any evidence of growth in the plowing and planting, and tending of the emotional and spiritual healing process. Words are my most valuable tools, and they can become yours too. And I really liked that part, that this isn’t luck, this isn’t that some people mended their relationships and other people just don’t.

This is making a deliberate choice to use these 11 words or whatever words come to you to step into that completion as you 

Dr. Ira Byock: call. Exactly. Exactly. And if anybody’s, you know, listening and. And thinking to themselves. Yeah. Right. You’re my audience. You, you’re my audience. You know, I, I’ve, I picked stories to address cuz I would be that reader.

Right. It skeptical. I, I’m the like Yeah, right. Sounds too glib. It’s the stories that, that I think open people up to the possibility of, well, you know, maybe so. Okay. There’s no harm in trying, and that’s, I, I go through that a fair amount in, in the book too, right? You can only take care of your side of any relationship, but if you show up and you that you know the, that’s 90% of life is showing up, the other 10% turns out entails arriving with good intentions.

Show up, arrive with good intentions, whatever happens, you’ve taken care of your side of the relationship. 

Diane Hullet: So well put. Well, I, I just love how you’ve encapsulated a lot of life experience and a lot of people’s stories into, you know, you really distilled it down to something pretty simple. And as you said, I love that you say, you know, this is not yours alone.

It’s not like you made this up. Many, many traditions have come to this same kind of sense of Yup, these are what matters. These, these are, these demonstrations of these words are what heal relationships and I go back to what you said in the beginning about this, this really important piece about how it is possible even in the face of death to die.


Dr. Ira Byock: exactly. I think that should be the next big thing in American culture. I. Ooh, say more. You know, we’re all about wellbeing in American culture, but it’s about physical health. So, you know, we, you know we buy organic foods and we you know jog and swim and bicycle long distances and, and we wear seatbelts and bicycle helmets and we floss, right?

But wellbeing. Is possible internal wellbeing. Being, being right with oneself, right? With one’s family, right, with the world, right with one’s maker. That’s also possible. And that’s possible through the very end of life. You can be well within your self even during the period of time that we would consider you to be dying.

And again, and as an old doc, my fondest. Goals for the people who were my patients, who are my patients, is that they be well, right? Yeah. I can’t make anybody immortal, but if I can support them in being well, I, they leave this life and. That that does it for me. 

Diane Hullet: That’s it. That’s it. That makes me think of another great writer, Stephen Jenkinson, in his book, wi Die Wise, he says, dying wise is an act of love.

It carries an abiding faith in life. It carries love for the world and it asks that same faith and love of those who attend to it. When it comes dying well is not the end of parenting, but the fullness of parenting. Not the end of a marriage, but the last great act of a married life. Dying Well is a bequest that you leave to those you love.

Probably the only thing that in the end will not be eaten by mods, apportioned by lawyers or bought for quarters in a yard sale. Beautiful. Dying well is the way you could be known by those. You won’t live long and enough to meet the way by which they might feel loved by you even after you were gone.

Yeah. Wonderful. Well, thank you so much for your time, Dr. Baek. I just really appreciate what you bring and what your books are bringing to the world and I, I love this. Let’s make Dying. Well, the new trend, 

Dr. Ira Byock: so. I, I think that’s what it should be. I think it will transform people’s lives to, to realize that they don’t have to fear dying.

They don’t have to, you know, look forward to it, but, but that it’s just another part of being human. It is about full and healthy living. Well, thank you very much for having me. It’s been a pleasure. Well, 

Diane Hullet: thank you so much for the conversation. I really appreciate it. You’ve been listening to the Best Life Best Death podcast with Dr.

Ira Bak. You can find out more about him and all the many, many good things he does in the world@irabak.org, and you can find out more about the work I do at Best Life. Best death.com. Thanks for listening.

Diane Hullet

Diane Hullet

End of Life Doula, Podcaster, and founder of Best Life Best Death.

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