| Authored by
RN, BSN, MA
The Omega Life Program
Johns Hopkins HealthCare
Glen Burnie, Maryland
Ira Byock, MD
Director of Palliative Care
Dartmouth-Hitchcock Medical Center
Lebanon, New Hampshire
Even the most healthy human
relationships are imperfect. That’s OK. But it tends to be true that
relationships would benefit from mending, tending and nurturing. The
Four Things That Matter Most offers thoughtful, poignant stories
that demonstrate how relationships can be healed and made richer in
a variety of different situations and phases of life. This
readers’ guide has been designed for use in classrooms and small
group discussions. Questions and exercises are provided to
stimulate discussion on how readers might view saying the Four
Things. It is hoped that readers will recognize how saying the Four
Things can reveal opportunities to forgive, love and grow –
individually and together – at any time in the course of
relationships and life.
Part One: The
Chapter 1: Saying The Four
Dr. Byock’s long experience in
emergency medicine and in palliative care (including hospice)
provides him with a unique perspective on life and relationships.
The stories in The Four Things That Matter Most are drawn from
end-of-life situations, yet the subtitle is “A Book About Living.”
- What might stories from such
situations teach us about living?
- If people we love know we love
them, and that we forgive them for previous tensions, why is the
value of “stating the obvious”?
- Can you think of an instance in
which relationship that was helped by expressing one or more of
the Four Things?
- Dr. Byock teaches that the
ancient origin of “good-bye” was the blessing, “God be with you.”
How often these days do people intend their partings to occur in
the spirit of a blessing?
- Can you think of a difficult
relationship that might benefit by saying one or more of the Four
- Practice saying one of the Four
Things this week. If you can, discuss the results with the
Chapter 2: The Healing Power of
- Mrs. Hargis
had thought long and hard about her decision to decline surgery.
What do you think of her decision?
- She thought
she had prepared for her life to end. From what took place in the
emergency department, do you think she was fully prepared?
- What did you
learn from the way Dr. Byock spoke with the family regarding Mrs.
- Discuss any
ideas you have for using the Four Things to reestablish or mend
relationship that has been strained.
- How might the
Four Things benefit people who have relationships that are
basically healthy, but because of illness or injury, are coming to
Chapter 3: Completing
Dr. Byock says that it is a quirk of the English language that
when we say a relationship is “complete” it implies that it is
ending. He explains that in referring to completing a relationship
he means that there is nothing left unsaid, that it is whole. Like a
circle, a relationship is complete when it is unbroken. Do you agree
that a relationship can be complete without necessarily ending?
Overcoming past hurts is possible.
- What do you
think about Lynn’s suggestion to Mr. Polansky regarding saying, “I
love you” to his wife? Were you surprised at what occurred?
- Diane Cahill’s
father was distant in his family relationships most of her life.
Discuss the “wake-up calls” that prompted him to make amends with
family and friends.
- No one is
promised that they will have a tomorrow. Diane reflects that it is
a good thing to say the things that matter most, “because you just
never know.” If you thought that someone you love – or once loved
– might die tomorrow, would it be important to you to make contact
with them today?
- Can you think
of situations in your own experience for which saying one or more
of the Four Things might be (or have been) of help in making the
Chapter 4: Transformations
Dr. Byock believes that
transformations are possible, even when they initially seem
unlikely. They sometimes happen when you don’t expect it.
- Steve Morris was a “Marlboro Man” in his style and was not
skilled in communicating about feelings or his relationships.
Discuss how he used the written list of the Four Things in a
concrete way to mend feelings with his family.
- Do you think it is
important to be outwardly emotional for the Four Things to work?
- The chaplain who told Dr. Byock about being called to the
bedside of the man dying from AIDS used the Four Things as a
clinical tool that enabled him to help this patient and his
newly-found teenage daughter complete their relationship.
- Dr. Byock says that in emergency situations time is not
measured in length, but in depth. He recounts that the victims of
the 9/11 attacks who made calls chose to say these things to the
people they cared about most in their lives. How did what they
said to their loved ones effect your thinking within your own
Return to Table of Contents
Part Two: Forgiveness
5: Loved Ones Live On Inside Us
1. What does Dr. Byock mean
by saying, “Forgiveness is a passage to a sanctuary of
wholeness, that nurturing place where we feel intimately connected
to the people who matter most to us.” (P 40)?
2. Discuss the
differences for Carla and Paul in their emotional healing (PP
3. Why would it be important for
Paul to continue to try to forgive his father and himself, after his
4. Do you think you might consider
writing personal notes to your children or other family members
using the Four Things, like Carla did?
Chapter 6: Resolving a Legacy of
What did the counselor mean by
advising Jennifer to “get it clear” between you if you can?
Jennifer describes a
recurring perpetuating pattern of pain across generations in their
family. Can you think of such families in your
- Jennifer’s Mom wanted the “bad stuff” to
stop with the grandson and the “good stuff” to go on.
Reflecting a family you know, do
you think it would be possible to stop the “bad stuff” and have the “good
stuff” go on?
Forgiveness may be the most important of the Four Things
in breaking destructive patterns in relationships between parents
and children. Can you think of situations in which expressing
gratitude and love would be critical in healing the rift between a
child and a mother or father?
Chapter 7: The Emotional Economics
Behaviors are often a
result of emotional pain.
1. Can you think of an instance
when, looking back, your own reaction at the time was “out of
bounds” due to pain from another issue?
2. The author asserts that anger –
even though it may be entirely justified – if carried around for
years ultimately harms the person who is angry. Do you agree?
It takes courage to forgive and ask
3. Avi had good reasons to be
angry with his father. Were you surprised at Lynne’s assertive
stance as a counselor in advising Avi that he needed to say the Four
Things to his father?
4. Lynne was pushed Avi because
she feels that there is little harm that can come from saying the
Four Things with good intention. What might have happened if his
father just turned away?
5. What do you think the effects
will be for Avi in the years to come?
Chapter 8: Extreme Acts of Forgiveness
“… hate keeps you chained to the
person you despise” (P 70).
Maeve had been sexually abused
by her father but was eventually able to forgive him with the
support of counseling.
What is the difference
between forgiveness and absolution?
Is it necessary to forget to
Maeve was determined to “become
whole.” Discuss what “becoming whole” means in relation to
forgiving someone who has hurt you severely?
The author feels that, “You
can only take responsibility for completing your side of the
relationship.” In both the story
of Avi and Simon from the last chapter, and in the Maeve’s story,
what would be the risk of reaching out to the person who harmed
them and having the attempt to reconnect fail?
Chapter 9: Forgiving Yourself
Susan struggled with her
ALS diagnosis and asked, “Why me?” She felt guilty as if she
had done something to cause it, even though intellectually she knew
the cause of ALS is unknown. Susan chose to put aside her
anger and focused her life on those around her.
Do you have something you
have felt guilty for that needs forgiving?
How might you handle this
guilt if you knew you had a terminal illness?
Knowing that no one is
promised tomorrow, is there something you could do today to forgive
yourself for past errors or indiscretions?
Can you extend the same
mercy to yourself for human error that you can extend to another?
What does it mean to be
your authentic self?
How does being your
authentic self help you to have “no regrets”?
Practice saying in the
mirror or to the person sitting next to you, “I am a good person,
worthy of love.”
believe you are worthy of
Chapter 10: Living with Uncertainty and Illness
Illness happens to all of
us in time. Mortality
dictates that there is an endpoint to this life.
Can you acknowledge that
you are not a bad person? A good person?
If you continue to feel
guilty for “having brought on” an illness, do you think you could
miss an opportunity for others to show love and care for you?
If you were a smoker and
developed cancer, would you feel guilty? Could you forgive yourself?
True or False: People who
never smoke, never die.
imperfect…is a common thread for all.
Discuss how changing
focus to allow others to feel good about themselves by helping care
for you could enrich the lives of all involved.
6. What does Dr.
Byock mean by “wholesome codependence”?
7. How do the
communities to which you belong help people during times of illness,
death and grief?
8. What community
support systems and activities could be strengthened?
9. If your parent
were to become ill, are there support systems in place at your job
to help you in caring for them?
What does Dr. Byock mean
by saying, “If you want to take good care of them, let them take
good care of you.” (P 95)?
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Part Three: Thank You
Chapter 11: Practicing Gratitude
Feeling that what you’ve
done in life has been appreciated is important. We can
validate someone’s contributions by saying “thank you.”
Does it feel awkward to
say “Thank you” to people who you work with frequently? Does it feel
awkward to have people say “Thank you” to you?
Practice saying thank you
to someone in the group for what you appreciate about them.
How might you practice
saying thank you to those in your family? At work?
Dr. Byock expresses that
in accepting gratitude you complete the transaction in a way that
affirms and strengthens the relationship.
Can you think of an
example of a person saying thank you in a way that you admired or
felt was well-received?
How do you like to be
Practicing gratitude helps us focus
on the positive. Gratitude breeds joy.
What are the things that
give you most joy in life?
Talking about happy times can bring
a smile to a dying person’s face.
What did Ernesto and
Julia do to help “leave a legacy” for their family?
How did Ernesto’s final
meeting and his manner of expressing gratitude in saying good-bye to
Dr. Byock affect you?
Chapter 12: The Unexpected Grace of
Dr. Byock reminds us that
“stating the obvious” is not always easy, especially with dementia
patients. Remember that profound moments are always possible.
Have you ever had a
meaningful interaction with someone who was “not all there?”
Can you think of ways of
expressing gratitude and enjoying the moment with a friend or
relative who has dementia? If so, describe your own feelings about
Are you grateful for the
“little things” as well as the “big things” in your life? If so,
what are some of those little things for which you are grateful?
Chapter 13: The Family Dynamics of
Blended families as well as
traditional families have ever changing dynamics. Learning to
say the Four Things may create a change in those dynamics.
How did the dynamics
change between Arlene, her step-brothers and step-sisters and her
If you had heard the
situation between Arlene, her mother and her step-siblings
described, but had not read “the rest of the story”, would you have
thought it possible that warm, supportive relationships could have
Conrad was able to say thank you
and I love you to his wife Hazel.
How did this affect
What unfinished business
was Arlene then able to accomplish with Conrad?
▲ Return to Table of Contents
Part Four: I Love You
Chapter 14: Creative Ways of Saying
the Four Things
Why is saying, “I love you” so difficult sometimes?
What gets in the way? ow did Gunter’s action of shaving his father
create a unique opportunity to say, “I love you” and “good-bye”
How did the ritual shaving help Gunther and his
father to come full circle?
Define “tender loving care” in the context of caring
for the dying person.
Chapter 15: Loving the Body
Paul wrote in his letter to
the Corinthians, “Faith, hope and love…But the greatest of these is
Horace and Louise were horrified to learn that their
son was gay. How did demonstrate love for their son during his dying
What do you think of Horace Whitman’s decision to
take physical care of his son? Given his strong feelings about his
son’s homosexuality, did his decision surprise you?
Discuss how it is possible to love a human being but
to dislike an action.
Can you imagine yourself in the shoes of a parent
whose child had committed a violent crime or otherwise done
something awful? How might you cope? As a parent, do you think you
would still be able to express love for your child?
Chapter 16: Living Every Day as if
It Were Your First-or Last
Every parent’s worst nightmare
is to lose a child.
- Why did
Gabrielle’s parents ask for her forgiveness?
- How did
Gabrielle’s father, Adam, help relieve doubts for her?
Yvette described the moment of
their letting go of Gabrielle as being intense and perfect.
- Why do you
think that moment felt so “grounded and connected” to Yvette?
- What do you
think about how Gabrielle’s wish to eat chocolates and champagne
was carried out?
Gabrielle’s parents celebrated
her birth and her death.
- If you could
have your dying wish fulfilled, what would it be?
- If you feel
comfortable doing so, write down what your dying wish would be and
share it with the group.
Chapter 17: Lives Intertwined
- Do you know
two people whose lives are, or were, “joined at the hip”?
- If either of
them has since died, what happened to the other? If both are
alive, what do you suppose might happen if one of these
individuals were to die?
- What was so
unique about the way Lisa and Linda communicated?
- Why did Lisa
feel the need to ask forgiveness for not being ready for Linda to
- Lisa and Linda
didn’t actually forgive each other verbally. Do you think they
needed to say the words, or do you feel they knew each other’s
heart and mind?
▲ Return to Table of Contents
Part Five: Good-bye
Letting go is never easy.
- Have you ever
said a good-bye and later regretted the things that were never
- In the last
letter Daniel wrote to his Mom he described the time he was dying
as “the best part of my life.” In what ways could that have been
- Discuss the
statement, “To love truly is inevitably to experience loss” (P
Chapter 18: Nothing Left Unsaid
Why didn’t Matthew ask Sara Ann to marry him before
he went to war? Do you think this was a sign of maturity or
How did Reverend John Williams and Matthew use the
Four Things before Matthew went to war?
Betty Williams was used to
protecting her son but realized that she could no longer do that.
What do you think about Matthew’s comment to his
mother when Betty said to him, “I realize I can’t protect you
anymore”? (P 183).
How did saying the Four Things help Betty and John
deal with the idea that Matthew could be captured, wounded, or
Can you think of times in your life in which people
left for long and possibly dangerous trips? Were there anything left
“unsaid” in your relationship?
Chapter 19: The Mysterious Magic
of Some Good-byes
- Have you ever
witnessed a dying person appear to hold onto life until after a
special anniversary, holiday, birthday, birth or until after the
last relative from out of town arrives for a final visit?
Withdrawing life-support is
always a difficult decision. Ann knew that Sandy wouldn’t want
to live like that.
- Would you be
able to make the decision to withdraw life-support for your loved
one? Why or why not?
- Mr. Cummings asked Dr. Byock to
assist ending Sandy’s life. What do you think of Dr. Byock’s
- The timing of
Sandy’s death surprised Dr. Byock. Did it surprise you?
- If Sandy’s
heart had not been restarted when he first collapsed, what
opportunities might have been missed for Mr. and Mrs. Cummings?
Chapter 20: Good-byes That Are
Gifts Through Time
- Have you ever
wondered whether is was a good idea to hold “celebrations of life”
at memorial services?
- What do those
celebrations do for the family and friends of the deceased?
Getting the chance to say
good-bye to a dying person is valuable not only to that person but
also for those left, after the person dies. Celebrations while the
dying person is still alive can be very meaningful.
What did it mean for Rose
to “hold court” when she was saying good-bye?
How did her family and
friends help Rose in her transition from this life?
Are there ways in which
you think that the transitions of birth and death similar?
Do you think Rose
orchestrated saying good-bye to her family?
Rabbi Hafez Hayyim told a
tourist that he (Rabbi) was only a visitor here.
7. What did Rabbi Hayyim mean by his comment to the
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Reflections Before Good-bye
Each generation has their issues
and makes mistakes. None of us have been perfect. There are
unique challenges for the Baby Boomer generation in caring for their
children and the seniors in their lives.
Can you think of ways to
express forgiveness, gratitude and positive feelings within
communities? Across generations?
2. Dr. Byock says
that the Four Things have become a practice in his own life. Do you
think you might use the Four Things in your daily life?
3. Do you think
that if saying or expressing the feelings of the Four Things was to
become common that relationships between generations would change?