354 – What the dying can teach us about living well: lessons on life and reflections on mortality

Bridget emphasizes that while most people say they want an advance directive, few actually do it. The most critical element is the proxy, not the checkbox list of procedures. She encourages imagining the scene: if you're incapacitated, who do you want making decisions? She suggests framing the conversation around what experiences are essential for quality of life—'I want to be in my garden, hear my family's voices'—so the proxy knows how to advocate for a scenario that allows those, rather than just saying no to intubation. BJ adds that the proxy's job is to speak for you, not impose their will; that requires deep knowledge of your values. Peter Attia shares that when asked to be a proxy, he insists on a dinner with wine and an open discussion because he wants to truly understand the person's desires.

BJ explains that a common misconception is that palliative care is just symptom management, but that's only the start. He says, 'in some ways the first thing to do is turn down the symptoms the degree possible so that the rest of you is present.' Once the nausea or pain is managed, the patient can talk about their fears, unfinished business, or spiritual crisis. Bridget adds that when symptoms are loud, 'you're not going to tell me how you're feeling other than the nausea.' The work then shifts to relationship building, advanced care planning, and existential work. The speakers also note that suffering is different from pain; someone can have minimal pain but massive suffering, and vice versa. The art is to titrate comfort enough to enable the deeper conversation.

Bridget tells families that the dying process is a lived experience for everyone in the room. She sees people refuse to leave for seconds, even to use the bathroom, fearing they'll miss the final breath. She and BJ both affirm that many patients seem to need solitude to die. BJ says it may be 'exactly the thing that person needs.' They advise normalizing this: it's okay if death occurs in your absence; it doesn't mean you failed. The point is to care for the living as well, and not to impose a medicalized, hyper-vigilant death.

The speakers address the cultural baggage around opioids. People worry about addiction, or that getting 'the morphine' means euthanasia. BJ clarifies that no one is 'killed' with morphine; it's titrated to comfort, and doses are not aimed at ending life. He often proactively explains, 'you're not going to get addicted to these medicines.' For those in recovery, he explores what sobriety means to them and reassures them that using prescribed opioids for comfort does not break their sobriety if they consent. He emphasizes that they can change their mind later. Bridget adds that some people believe pain is redemptive or refuse all medications; their wishes are honored, though they may suffer more.

BJ says the work of preparing for dying begins earlier in life, not at the deathbed. He advocates for 'daring to look and to see and to be true to ourselves.' Bridget adds that we don't know when we'll die, so the invitation is to be tender now, to act from your values now, because this moment is all you have. She says we can all practice by noticing death and life around us. The speakers also caution that one can feel like a failure at dying; thus, the goal is not an idealized death but an honest, connected, and forgiving approach to whatever unfolds.

BJ emphasizes that the early work is 'so much of relational, getting to know the person, laying out a sort of a safe place for them to fall apart, share their fears without being shushed.' He says you might not ask about the diagnosis for several visits. By gathering knowledge about what matters to the person, the provider can later anticipate upcoming challenges and tailor conversations to that individual. Bridget adds that she often just asks, 'how has this been for you?' and listens without trying to fix or minimize. Many patients haven't had anyone simply ask that question; oncologists or neurologists are focused on treatment.

BJ and Bridget argue that palliative care is fundamentally good healthcare—sitting down, introducing yourself, asking 'how has this been for you?' These elemental relational acts are often skipped in today's medicine. The team includes doctors, social workers, chaplains, and therapists. Its goal is quality of life as defined by the patient. Because of confusion between hospice and palliative care, people say 'I'm not ready for palliative care' when they really mean 'I'm not ready to stop fighting.' Once they understand, they often ask, 'Why wouldn't I want this?' Yet systemic barriers (staffing, billing, culture) keep referrals low. The speakers emphasize that palliative care is not easy; it requires a real skill set to time questions, listen for existential distress, and build trust over multiple visits.

BJ explains that as his career progressed and he integrated non-medical perspectives, he stopped automatically medicating delirium. He now sees it as potentially vital—maybe the person is expressing something important. He emphasizes that dying shouldn't be forced into a tidy, silent 'good death.' Instead, he'd have a conversation with the patient earlier: 'If you become confused, would you rather we medicate it and help you sleep, or let it run its course?' He underscores that death is messy, and the family's interpretation of final words should be held lightly, because delirium means the person is not themselves.

Bridget shares that when she helps someone create an advance directive, she tries to understand what experiences are central to their good days—being in the garden, hearing a loved one's voice—and then asks, 'what do we need to get you there?' rather than listing what not to do. BJ adds that the proxy's role is to honor the other person's wishes, which requires a deep conversation, not just a signature. He notes that the job is not to insert one's own will. The speakers also caution that people adapt more than they expect; preferences may shift with illness, so the conversation must be revisited. Peter Attia shares that when asked to be someone's proxy, he insists on a dinner conversation with wine to truly understand their wishes.

BJ elaborates that many people spend a lifetime running from fear, but when they accept that fear is natural, it becomes defanged. The same with regret: the lesson isn't to live without regret, but to accept all parts of yourself, even the gnarly stuff. He says, 'to get to feel anything is kind of wild and magical.' This insight leads to the advice to start living honestly now, because people die as they lived. If you want a death with connection and authenticity, practice those muscles today.

Bridget notes that this phenomenon is well-known in hospice. She encourages families to take care of their own basic needs and to give permission for the person to die in their absence. BJ adds that it's possibly the thing the dying person needs to finally let go, and that 'you going to the bathroom or taking a walk or stepping in the room may be exactly the thing that that person needs.' The advice is to not impose a vigil that might prolong the struggle.