“I have to accept that I’m not going to live forever. That’s not great, but there are no exceptions.” When Hansjörg Znoj thinks about how we deal with death, he always comes back to one point. He says: “The key word is acceptance.” The psychologist has dealt very intensively with grief. He says it’s an emotional response to the fact that the world is no longer the way you think it should be. This is exactly what happens when you lose someone close to you. It is a shaking up of your own conception of the world. Ultimately, according to Znoj, grief is a universal, biological process that takes place after such a shock – even though our idea of grief is transmitted culturally and we, as bereaved people, are sometimes confronted with societal expectations. A kind of grief, a pain of parting is also probably part of the whole process even if you are not having to let another person go, but instead are dying yourself. Don’t we all imagine it being incredibly difficult for us to say goodbye to our own lives? According to Znoj, acceptance plays an enormous role here. We have to come to terms with the fact that our lives will end sooner or later. “Like grief, dying is, among other things, about detaching yourself from ideas. This can also be liberating,” says Znoj.

He not only believes that preparing for one’s own death is possible to a certain extent, but he even sees dealing with death as a task that we humans have in life. Other specialists also agree with this statement.

End of life as a social issue

Palliative medicine specialist Steffen Eychmüller supports people at the end of their lives. They and their relatives should receive comprehensive care here. Eychmüller says: “I am convinced that you can and must prepare for your death.” He sees this not only as an individual task, but also as a social one. “A society that deals with the end of life and dying is probably much more mature when it comes to death, but also more conscious about life.” This is something that Eychmüller feels is lacking in our current society, and which is reflected in politics. He draws a parallel to the beginning of life: Birth, like dying, is an existential event. Even at birth, it is not possible to know exactly what to expect, but today we know very well what it takes to provide the best possible support for a birth. That’s also something we know about death. The difference is that in obstetrics, financing is ensured in such a way that medical care, birth preparation and support in various settings, as well as paternity and maternity, are clearly regulated by law. “None of this exists at the end of life. It all starts with someone whose relative is dying not being able to take a vacation, but having to take sick leave if they want to accompany the dying person,” says Eychmüller. Unfortunately, funding is not well regulated in hospitals. Anyone who does not want to be relocated again at the very end of their life has to “die under a certain amount of time pressure” because the length of stay in hospital is de facto limited due to the reimbursement via flat-rate per-case payments. “This is actually the end of civilized society,” says Eychmüller.

What if?

In order for this to change, we should all come to terms with our finiteness and give the end of life a much higher value in society, says Eychmüller. That sounds more challenging than it perhaps is. “Occasionally, we might ask ourselves: What if my life ended soon?” says Eychmüller. If we were aware that our life could be over at any time, it wouldn’t seem so strange to us, so unpleasant, to think about our own death. Eychmüller thinks we have plenty of opportunities to do this in life. For example, if a person dies in our extended circle, we are often affected. In these situations, we could ask ourselves: What would it feel like if it was someone from my closest family? Or me? Would we be reasonably prepared today? Would we have said all the important things we wanted to say to each other? “We can choose to address the issue at such a moment, or we can put it off and move on, only to realize at some point that we have missed out on having those important thoughts in life,” says Eychmüller.

In his day-to-day work at Inselspital, he often experiences people being completely taken by surprise at the end of their lives, even though they have usually been seriously ill for a long time. Often, everyone involved is overwhelmed, and it is something that becomes difficult to endure, difficult to bear even though that would have been important. “The topic of relationships comes up again and again. As studies have shown, it is in fact our relationships that are beneficial in life and at the end of life.”

Talk, talk, talk

In order to stimulate thoughts and discussions about dying, the palliative care physician and researcher is involved in various initiatives. For example, with the city festival “Endlich.Menschlich,” which takes place in Bern in October and – parallel to the scientific congress being held at the same time – aims to stimulate debate in society about what a dignified end to life means. Or with his book “Das Lebensende und ich” (The End of Life and Me), which he published together with communication scientist Sibylle Felber. Felber is a research associate at Inselspital Bern and, like Eychmüller, is part of the “Palliative Care and End of Life” research group, which Inselspital runs together with the Institute of Social and Preventive Medicine (ISPM) at the University of Bern. The book is subtitled “Suggestions on how to deal with our finiteness more easily”. Regular conversations about life and death are important, says Eychmüller. Just talking about it over and over again is crucial. If necessary, suggestions can be found on what should be discussed in detail. “If we prepare ourselves and accept our own finiteness, life also becomes more intense. We celebrate it all the more,” says Eychmüller with conviction.

How do I want to live?

Isabelle Noth agrees. Among other things, the pastoral counselor heads up the “Spiritual Care” course at the University of Bern. She says: “When we realize that our time is limited, we inevitably ask ourselves: How do I want to live? What is important to me in life?” Very often, according to Noth, it becomes clear to us how elementary it is to be connected to other people and to the world.

In the pastoral care of people at the end of their lives, she and her colleagues, just like Eychmüller and his team, discovered that many people become aware of the importance of relationships in death, says Noth. Sometimes precisely because some relationships do not exist or are unable to bear in this existential situation. At the end of their lives, people also ask themselves questions such as: Why didn’t I dare to listen to myself sooner? Why have I spent my life doing what I thought was expected of me? Alternatively, why haven’t I been able to be more generous or brave, perhaps more understanding or forgiving?

“At the end of their lives, people often suffer less from having to die than from not having lived their lives properly. Living life to the full, exposing oneself to life completely, enjoying it and cultivating relationships is therefore certainly a very good preparation for one’s own death,” says Noth. To the full means the good, the great, the beautiful as well as the bad and the ugly. You could live with that – and eventually die.

Preparation means clarification

Taking care of unfinished business also helps you to feel more relaxed at the end of your life. You don’t have to wait to do that until death is knocking at your door, because clarification also helps in the middle of your life. Of course, it is important to answer practical questions such as those about medical decisions, some of which can be regulated in advance in a living will. Or questions about legacies and financial matters. But these are all things that are more or less easy to manage and for which information is accessible. Other things are often less simple. “Life issues that have not been considered for a long time can be very stressful and can hurt enormously at the end of life,” says Isabelle Noth. For example, a difficult relationship with your parents or injuries that have never been discussed. Such unspoken things sometimes weigh heavily at the end. “Unfortunately, we see this again and again in pastoral care,” says Noth. So tackling these issues during your lifetime could also be helpful with regard to your own final stage of life. And what about the much-cited self-determination until death? According to hospital ethicist Rouven Porz from Inselspital, University Hospital Bern, medical decisions at the end of life focus on the patient’s will. This gives us the autonomy and power to make our own decisions. Porz, whose work includes the implementation of clinical ethics in Swiss healthcare institutions, says: “We insist on our self-determination. So we also have to think about what we need to do.” So we are expected to express our will. Self-determination is therefore not only a right, but also an obligation that we must fulfill. And here too, according to Porz, we must not forget that, for all our self-determination, we are not isolated individuals, but social beings in relationships with others. They are also affected by our decisions – possibly beyond our own lives.