Psychological Considerations, Growth, and Transcendence at the End of Life: Title and subTitle BreakThe Art of the Possible

Let it come, as it will, and don't
be afraid. God does not leave us
comfortless, so let evening come.—From "Let Evening Come," Jane Kenyon (1996)

In June 2001,¹ Susan Block, MD, introduced Mr N, aged 77 years, a divorced systems analyst with end-stage pancreatic cancer metastatic to the liver and lungs; Mr N's adult son; and his treating physician, Dr S. Each described the psychological challenges, and illuminated the potential opportunities for personal growth and deepening of relationships, that the end of life offers. Careful attention to Mr N's physical symptoms and suffering made it easier to address his central concerns—about family, his own psychological integrity, and about finding meaning in his life.

Four months after Mr N's June 1999 interview, his condition worsened. Mr N called Dr S to say that he was experiencing marked anorexia and increasing weakness and was thus unable to come to outpatient clinic appointments any longer. He was ready to engage home hospice. While Dr S arranged this, his son came from his home in another state to help care for his father. Later, Mr N's ex-wife joined them.

Along with the hospice nurse, Dr S continued to see Mr N at home, initially visiting weekly, then, during the last week of his life, every other day. Mr N remained conscious, lucid, and conversant until about 36 hours prior to his death. During one of these visits, Mr N pointed out to his son the shelf of books that he and his physician had read and discussed together. Dr S admired the son's care and observed to the son that he undoubtedly would later treasure the time and effort spent in caring for his dad, noting a book he and Mr N had read whose author described the dying and the caring for the dying to be 2 halves of a whole.²

Dr S recommended to the son and ex-wife that they read 2 companion works of poetry: the final collection of poems by Jane Kenyon, entitled Otherwise (1996),³ and the response by her husband, Donald Hall, entitled Without (1998).⁴

Mr N's son managed his father's agonal symptoms with oral and rectal morphine, lorazepam, and atropine. Mr N died peacefully, in his own bed, as he had wished. Mr N's son, his companion, and his ex-wife later reflected upon his life and death in correspondence to Dr S.

All I can say is thank you for being in [my father's] life as his doctor and friend, and thank you for guiding him and me through his death. Reading the JAMA article I realize I had no idea what losing [Dad] would be like. I don't know that I'd change what I said, but my state of mind is certainly different. Also, I've been taking some biology classes, in part because of [him].

You were [his] anchor in a stormy sea—thank you for being there for him—in every way. He loved and admired you deeply. My heart is with you. . . .

Thank you again for all the loving care you gave to [Mr N] over the years and particularly these last months and hours. How much like [Mr N] was Jane Kenyon in her last days when she said, "Dying is simple. . . . What's worse is the separation." Exactly what he expressed, that he was content with dying, but it was leaving our son and me and his close friends who would be left to grieve—that's what concerned him. He was quite a wonderful person, wasn't he?

Recently, I walked down to the park with my friend and we sat for more than an hour on the bench that was donated by Mr N's friends. It was a fitting tribute to this special man, whom I miss so in my clinic.

These things happen . . . the soul's bliss
and suffering are bound together
like the grasses. . . .—From "Twilight: After Haying," Jane Kenyon (1996)