Dealing with Grief - Four Things
When delivering end-of-life-care, it’s easy to narrow focus and attention on mending physical symptoms. Managing pain, breathlessness, and skin integrity are essential and tangible. However there is another component to address. Existential suffering is just as impactful and often feels nebulous to navigate.
When patients face the end of life or significant health crises, suffering often stems from "unfinished business" in relationships. The Four Things framework can help us alleviate that distress by providing a clear script to bring closure. Based on the work of palliative care physician Dr. Ira Byock, the framework consists of four simple phrases:
- Please Forgive Me
- I Forgive You
- Thank You
- I Love You
“Please forgive me."
This phrase acknowledges ours imperfections. No relationship is perfect. Even in the most stable of families there are moments of impatience, conflict or absence. Acknowledging our own imperfections can be freeing for both the patient and family.
"I forgive you."
Granting forgiveness is one of the greatest acts of kindness. This releases one from any debt, whether it’s real or perceived. Dying patients often hold onto guilt regarding past harms or the burden they feel they are placing on others. For many this can be a stumbling block - it’s important to separate granting forgiveness from reconciliation. Granting forgiveness is not synonymous with condoning bad behaviour or past actions. It simply means setting aside any resentment.
"Thank you."
This phrase validates the person’s life and worth. It affirms that their existence mattered. You can be general and thank them for their presence but specificity helps. Thank them for their presence, their lessons, or their unique impact on your life.
"I love you."
There is no stronger affirmation. The framework begins by letting go of our imperfections and ends by offering the best parts of ourselves.
This model was recently highlighted in the medical drama The Pitt (Season 1, Episode 4), where Dr. Robby uses the "Four Things" to support a family struggling to say goodbye.
Working through grief and loss is challenging. It’s challenging for our patients and I’ve seen many physicians struggle to find the right words in these moments. It’s important to distinguish curing a medical condition from healing. Even if a condition cannot be cured, healing is still possible. If you’re in practice and you struggle with end of life conversations, I encourage you to take a look at the Four Things framework. It offers a gentle, structured path for patients and families to navigate the complexities of saying goodbye.
Watch: Dr. Byock: The Four Thing That Matter Most
Sources: Byock, I. (2004). The Four Things That Matter Most.