No matter what your patient has done in her life, she can create a legacy. She can gain a place in the hearts and memories of people if she weaves love, gratitude and forgiveness into the last chapter of her life story. This is the simple, yet profound, wisdom that comes from Dr. Ira Byock’s identification of the four statements that matter most in life: “I love you.” “Thank you.” “Forgive me.” “I forgive you.”[1]
So, encourage your patient to reflect on and respond to questions like the following:

• “Who are the people who matter most to you?” “How can you let them know what they mean to you and how you feel about them?”
  
• “Who are the people who have helped you become the person that you are?” “How would you like to thank them?”
  
• “What unresolved hurts or conflicts are you carrying?” “Are you ready to let them go and to forgive those involved?” “How could you do this?”
  
• “Are you aware of people who feel you have hurt or wronged them?” “Are you ready to ask for forgiveness so that you can restore your relationship?”
  

You might also suggest that she identify the people who mean the most to her and to select a personal memento (preferably from possessions that have been important to her) that symbolizes what she appreciates about the person. The memento could be as simple as a photograph or as significant as a treasured piece of artwork or jewellery. If possible, she could arrange times to meet with the recipients to present her gifts and to tell them what they have meant to her and what her wishes are for them. Preparing a note to go with each gift could help her make sure that she expresses what is important to her about the relationship. Such a gift may well become a lasting treasure and precious memory for each person. If she does not have the strength or energy to prepare these gifts and notes, perhaps a friend, family member or hospice volunteer could assist.

Finding opportunities to review and share her life story might also be helpful in establishing her legacy. (See Sharing My Story for ideas on how she might do this). Having another person listen to her story will highlight its significant moments and relationships, and affirm the meaning of her life. By sharing her story, she may realize that in the living of her life she has already created a legacy.

Dignity therapy is a more formal approach that guides patients through a reflective process. During one-to-two-hour sessions, patients are encouraged to focus on aspects of their lives that have mattered most, and to consider what they wish to say to those they are leaving behind.[2] The sessions are audio-recorded, transcribed and edited. The result is a written legacy that can be given to loved ones in accordance with a patient’s wishes. Studies evaluating patient satisfaction with dignity therapy report a 91 percent satisfaction rate, with 76 percent of patients reporting a heightened sense of dignity after participating. [3] Dignity therapy asks patients to respond to questions like the following:

• “What parts of your life do you remember most or think are the most important?” “When did you feel most alive?”
  
• “Are there specific things you would want your family or friends to know about you?” “Are there specific things you want them to remember?”
  
• “What are the most important roles you have played in life (family roles, vocational roles, community-service roles, etc.)?” “Why were they so important to you, and what do you think you accomplished in those roles?”
  
• “Are there particular things that you feel still need to be said to your loved ones, or things you would want to take the time to say once again?”
  

Whether palliative professionals use dignity therapy in a formal, structured way or not, questions like the above can guide a health care team in helping patients to do legacy work. Dignity therapy has proven to be an effective way of helping dying patients preserve their self-respect and leave a legacy.

References

1. Byock I. The Four Things That Matter Most: A Book About Living. New York, NY: Free Press; 2004.

2. Chochinov HM. Dignity Therapy: Final Words for Final Days. New York, NY: Oxford; 2012.

3. Chochinov H, Hack T, Hassard T, Kristjanson L, McClement S, Harlos M. Dignity therapy: a novel psychotherapeutic intervention for patients near the end of life. J Clin Oncol. 2005; 23(24):5520-5525.