Volume 24, Number 9: September 2023

Wisdom That Stands the Test of Time

The Four Things That Matter Most: A Book About Living. 10th anniversary edition, re-released
Ira Byock
Atria Books, 2014
Hardcover, pp 246
MSRP: $18 USD

By Frank Brennan, MD

There are a few acknowledged classics in the literature of serious illness, death and bereavement. The Death of Ivan Ilyich by Leo Tolstoy, On Death and Dying by Elizabeth Kubler-Ross, Mortally Wounded by Michael Kearney, Being Mortal by Atul Gawande, A Grief Observed by C.S. Lewis, and The Year of Magical Thinking by Joan Didion. The Four Things That Matter Most by Ira Byock deservedly stands among these titles. First published in 2004, it was republished with revisions a decade later. Next year marks its 20th anniversary, prompting the publisher to re-release the book.

Ira Byock is an American palliative care physician, author, and public advocate for improving end-of-life care. The premise of his book appears simple but its content demands close reading. The author commences by describing the challenges that people with serious life-limiting illnesses and their families and loved ones have articulating their deep thoughts to each other. Time is precious. Much may be left unsaid. Much may be assumed but never articulated. To Byock, the four statements that matter most in these conversations are: “Please forgive me." "I forgive you." "Thank you." "I love you.”

Separated and discussed in detail, the wisdom of these statements is highlighted by the intensity of the context. People may have a very short time to live. The opportunity for conversations is now finite. The weight of the unresolved past may lie very heavily on patients and their family members. Byock illustrates each statement with a series of beautifully recounted clinical encounters. In these encounters, the ache behind argument, neglect, and dysfunction within families is palpable. The liberation felt by all when forgiveness is finally sought and given, gratitude expressed, and love that may have laid dormant for decades, is articulated.

Truthfully, Byock acknowledges the difficulty for many people and families in saying these words. Surely, gratitude, forgiveness and love can be implied in the living of shared lives? Do these statements need to be expressed explicitly? Throughout the book, Byock resists being prescriptive. Nevertheless, through his explanation and, especially, through the clinical stories, he illustrates the power unleashed by articulating these words in transforming the feel and nature of the end of life of an individual.

Put simply, the focus of the author is making “recommendations for mending, tending, and celebrating relationships.” Correctly, Byock acknowledges that this process is a lifelong project and is not necessarily reserved for the end of a person’s life.

Almost two decades on, Byock’s book is worth rereading or, if you are coming to this work for the first time, savouring its wisdom borne through life experience and the extraordinary insights drawn from repeated, attentive contact with patients and families.

Dr. Frank Brennan is a palliative care physician, past president of the Australian and New Zealand Society of Palliative Medicine, a senior lecturer in the Faculty of Medicine at the University of New South Wales, and a lawyer. 

New on the Shelf

Listening for What Matters: Avoiding Contextual Errors in Health Care, 2nd ed. Saul J. Weiner, Ala Schwartz. Oxford University Press, 2023. ISBN: 978-0197-588109. Softcover, $45 USD.

LGBTQ+ People and Dementia: A Good Practice Guide. Elizabeth Price, Sue Westwood. Jessica Kingsley, 2023. University of Bradford Dementia Good Practice Guides series. ISBN: 987-1839-973307. Softcover, $22.95 USD.

50 Studies Every Global Health Provider Should Know. Andrea Walker, Anup Agarwal, Yogesh Jain, editors. Oxford University Press, 2023. ISBN: 978-0197-548721. Softcover, $60 USD.

Digital Mental Health: A Practitioner's Guide. Ives Cavalcante Passos, Francisco Diego Rabelo-da-Ponte, Flavio Kapczinski, editors. Springer, 2023. ISBN 978-3031-106972. Hardcover, $139.99 USD; €129,99.

Medical Assistance in Dying (MAID) in Canada: Key Multidisciplinary Perspectives. Editors: Jaro Kotalik, David W. Shannon. Part of The International Library of Bioethics book series. Published by Springer, 2023. Hardcover, $139.99 USD.