The Four Things That Matter Most – Readers’ Discussion Guide

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Prepared by: Leslie Piet, RN, BSN, MA
The Omega Life Program
Johns Hopkins HealthCare
Glen Burnie, MD
Ira Byock, MD
Executive Director and
Chief Medical Officer
Institute for Human Caring
Providence Health and Services
Torrance, CA



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 Four Things
Part Two:        Forgiveness
Part Three:     Thank You
Part Four:    I Love You
Part Five:     Good-bye
Afterword:   Reflections Before Good-bye


Part One: The Four Things

Chapter 1: Saying The Four Things

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.”

  1. What might stories from such situations teach us about living?
  2. If people we love know we love them, and that we forgive them for previous tensions, why is the value of “stating the obvious”?
  3. Can you think of an instance in which relationship that was helped by expressing one or more of the Four Things?
  4. 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?
  5. Can you think of a difficult relationship that might benefit by saying one or more of the Four Things?
  6. Practice saying one of the Four Things this week.  If you can, discuss the results with the study group.


Chapter 2: The Healing Power of Words
  1. Mrs. Hargis had thought long and hard about her decision to decline surgery. What do you think of her decision?
  2. 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?
  3. What did you learn from the way Dr. Byock spoke with the family regarding Mrs. Hargis’s choices?
  4. Discuss any ideas you have for using the Four Things to reestablish or mend relationship that has been strained.
  5. How might the Four Things benefit people who have relationships that are basically healthy, but because of illness or injury, are coming to an end?


Chapter 3: Completing Relationships

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.

  1. 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?
  2. 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.
  3. 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?
  4. 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 relationship whole?


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. 

  1. 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.
  2. Do you think it is important to be outwardly emotional for the Four Things to work?
  3. 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.
  4. 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 family life?


Part Two: Forgiveness

Chapter 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 45-47).

3.   Why would it be important for Paul to continue to try to forgive his father and himself, after his father’s death?

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 Pain
  1. What did the counselor mean by advising Jennifer to “get it clear” between you if you can?
  2. Jennifer describes a recurring perpetuating pattern of pain across generations in their family. Can you    think of such families in your own experience?
  3. Jennifer’s Mom wanted the “bad stuff” to stop with the grandson and the “good stuff” to go on.
  4. Reflecting a family you know, do you think it would be possible to stop the “bad stuff” and have the   “good stuff” go on?
  5. 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 of Forgiveness

 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 for forgiveness.

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.

  1. What is the difference between forgiveness and absolution?
  2. Is it necessary to forget to forgive?
  3. Maeve was determined to “become whole.” Discuss what “becoming whole” means in relation to forgiving someone who has hurt you severely?
  4. 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.

1.  Do you have something you have felt guilty for that needs forgiving?

2.  How might you handle this guilt if you knew you had a terminal illness?

3.  Knowing that no one is promised tomorrow, is there something you could do today to forgive yourself for past errors or indiscretions?

4.  Can you extend the same mercy to yourself for human error that you can extend to another?

5.  What does it mean to be your authentic self?

6.  How does being your authentic self help you to have “no regrets”?

7.  Practice saying in the mirror or to the person sitting next to you, “I am a good person, worthy of love.”

8.  Do you believe you are worthy of being loved?


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.

1.  Can you acknowledge that you are not a bad person? A good person?

2.  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?

3.  If you were a smoker and developed cancer, would you feel guilty? Could you forgive yourself?

4.  True or False: People who never smoke, never die.

Being imperfect…is a common thread for all.

5.  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?

10. 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)?


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.”

1.  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?

2.  Practice saying thank you to someone in the group for what you appreciate about  them.

3.  How might you practice saying thank you to those in your family?  At work?

4.  Dr. Byock expresses that in accepting gratitude you complete the transaction in a way that affirms and strengthens the relationship.

5.  Can you think of an example of a person saying thank you in a way that you admired or felt was well-received?

6.   How do you like to be thanked?

Practicing gratitude helps us focus on the positive.  Gratitude breeds joy.

7.  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.

8.  What did Ernesto and Julia do to help “leave a legacy” for their family?

9.  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 Reconnection

 Dr. Byock reminds us that “stating the obvious” is not always easy, especially with dementia patients. Remember that profound moments are always possible.

1.  Have you ever had a meaningful interaction with someone who was “not all there?”

2.  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 the event.

3.  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 Gratitude

Blended families as well as traditional families have ever changing dynamics.  Learning to say the Four Things may create a change in those dynamics.

1. How did the dynamics change between Arlene, her step-brothers and step-sisters and her mother?

2.  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 formed?

Conrad was able to say thank you and I love you to his wife Hazel.

3.  How did this affect Arlene?

4.  What unfinished business was Arlene then able to accomplish with Conrad?


Part Four: I Love You

Chapter 14: Creative Ways of Saying the Four Things

1. Why is saying, “I love you” so difficult sometimes? What gets in the way?

2. How did Gunter’s action of shaving his father create a unique opportunity to say, “I love you” and “good-bye” using touch?

3.   How did the ritual shaving help Gunther and his father to come full circle?

4.   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 love.”

1.   Horace and Louise were horrified to learn that their son was gay. How did demonstrate love for their son during his dying of AIDS?

2.   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?

3.   Discuss how it is possible to love a human being but to dislike an action.

4.   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.

  1. Why did Gabrielle’s parents ask for her forgiveness?
  2. 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.

  1. Why do you think that moment felt so “grounded and connected” to Yvette?
  2. 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.

  1. If you could have your dying wish fulfilled, what would it be?
  2. If you feel comfortable doing so, write down what your dying wish would be and share it with the group.


Chapter 17: Lives Intertwined with Love 
  1. Do you know two people whose lives are, or were, “joined at the hip”?
  2. 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?
  3. What was so unique about the way Lisa and Linda communicated?
  4. Why did Lisa feel the need to ask forgiveness for not being ready for Linda to die?
  5. 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?



Part Five: Good-bye

 Letting go is never easy.

  1. Have you ever said a good-bye and later regretted the things that were never said?
  2. 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 true?
  3. Discuss the statement, “To love truly is inevitably to experience loss” (P 177).


Chapter 18: Nothing Left Unsaid

1.   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 selfishness?

2.   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.

3. 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).

4.  How did saying the Four Things help Betty and John deal with the idea that Matthew could be captured, wounded, or killed?

5.  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
  1. 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.

  1. Would you be able to make the decision to withdraw life-support for your loved one? Why or why not?
  2. Mr. Cummings asked Dr. Byock to assist ending Sandy’s life. What do you think of Dr. Byock’s response?
  3. The timing of Sandy’s death surprised Dr. Byock. Did it surprise you?
  4. If Sandy’s heart had not been restarted when he first collapsed, what opportunities might have been missed for Mr. and Mrs. Cummings? For Ann?


 Chapter 20: Good-byes That Are Gifts Through Time
  1. Have you ever wondered whether is was a good idea to hold “celebrations of life” at memorial services?
  2. 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.

3. What did it mean for Rose to “hold court” when she was saying good-bye?

4.  How did her family and friends help Rose in her transition from this life?

5.  Are there ways in which you think that the transitions of birth and death similar?

6.  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 tourist?

Afterword: 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.

1.  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?

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