Miriam Greenspan, in her book Healing Through the Dark Emotions: The Wisdom of Grief, Fear, and Despair (Greenspan, 2003), defines the “dark emotions” using three words: grief, fear, and despair. She talks about the importance of exploring these “dark emotions.” As a result of such exploration, we can gain “wisdom” and insight that allows us to make better decisions and live a fuller life. Most people put off having conversations about their quality of life and about their values and EOL wishes. As a result, when the crisis happens, they have not yet had those meaningful discussions. In my work, I hear over and over again, “I wish we would have talked about it before the crisis happened.”

Life-threatening events happen not only to older adults, but unexpected, life-changing events also occur in the lives of young adults. Crises—car or sports accidents, strokes, and so on—happen to 18and 20-year-olds. Unexpected events do not happen only to those who are actively anticipating EOL realities. Examples of EOL/ACP choices that may need revision over the years are decisions related to organ, tissue, and eye donation. Have you shared your own thoughts regarding organ or tissue donation?


I taught for over 23 years, starting in 1989, a required 8-week course, 2 hours each week, for 54 second-year medical students. The course, The Psycho, Social, Spiritual Aspects of Life-Threatening Illness, was not intended for students to complete an exam by “remembering five points,” or answering multiple choice questions. My goal was to provide students opportunities to appreciate, along with becoming physicians, that in the future some of them may have their own family or be in an intimate relationship. Each year students had chances to make many of the same decisions their future patients and families would be deciding.

On the first day of the class the students were given a Minnesota Health Care Directive to complete by week #8. They were to “have the discussion” with their spouse if married, their partner or fiancée, and also with their own parents. Not only were they given a health care directive to complete, but the first day of class, each student was also “diagnosed” with a terminal illness they would die from exactly 1 day after taking the final exam—that was an exact prognosis! They were going to die and had only weeks to live. They contemplated who to talk with and what to say. They were asking the same questions that those they would be caring for
in the future would be asking, “What do I need to do now before my final days, my final hours?”

Each of the students also had various assignments to complete while they were “dying.” Writing a letter to the most important person in their life, to be read after they died, was one example. Each week I would remind them, “You only have X number of weeks left to live.”

In addition to each student “dying” over the length of the course, one third of the class each year, along with attending the classes and doing the required assignments, followed a real-life terminally ill person (known as a “friend,” not a patient) and that person's family. They spent at least 1 hour a week in the person's own home, or wherever the person with his or her terminal illness was living. I would also meet with this particular group of students every 2 weeks to process the experience.

When it came to asking their dying “friend” about his or her health care directive, it became clear it was more than just having someone witness or notarize a document. Students learned the difficulties of having conversations that many “friends” had never had previously. The definitions of “quality of life” had changed from what the definitions might have been in previous years when the dying persons were more fully capable in the physical or cognitive aspects of their lives.

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