Wisdom at the End of Life

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Wisdom is typically considered to be the fruit of a long life, the accumulation of experiences lived and lessons learned. In recent years, scientists have created a consensus definition of wisdom as a complex trait with several inter-related components, such as compassion, emotional regulation, spirituality and tolerance.  

In a paper publishing January 24 in the journal International Psychogeriatrics, researchers at the University of California San Diego School of Medicine asked 21 hospice patients, ages 58 to 97 and in the last six months of their lives, to describe the core characteristics of wisdom and whether their terminal illnesses had changed or impacted their understanding of wisdom.

“The end of life presents a unique perspective,” said senior author Dilip V. Jeste, MD, senior associate dean for the Center of Healthy Aging and Distinguished Professor of Psychiatry and Neurosciences at UC San Diego School of Medicine. “This is an extremely challenging time, a confluence of learning to accept what’s happening while still striving to grow and change and live one’s remaining life as best one can. It’s this paradox that, if embraced, can lead to even greater wisdom while confronting one’s own mortality.”

Jeste and colleagues have spent years studying the nature of wisdom, from its definition and assessment to its neurobiology. In the current study, consenting participants (all residents of San Diego County, primarily Caucasian and both men and women) were interviewed in their homes or in health care facilities by mental health professionals using a semi-structured guide. Nearly half were dying from cancer.

All were asked the same set of questions, such as “How do you define wisdom?” and “What experiences have influenced your level of wisdom?” The interviews were open-ended to allow participants to introduce or expand upon topics of importance to them. The interviews were audiotaped, transcribed, analyzed and interpreted using a variety of evaluative methods.

In order of importance, participants ranked the defined components of wisdom to be prosocial behaviors, social decision making, emotional regulation, openness to new experience, acknowledgement of uncertainty, spirituality, self-reflection, sense of humor and tolerance.

Perhaps not surprisingly, serious illness, a diagnosis of terminal disease or the beginning of hospice care significantly altered their conceptualization of wisdom. “My perspective, my outlook on life, my outlook on everything has changed,” said one study participant. “It’s grown tremendously.”  

The study authors said a recurring theme among interviewed hospice patients was their search for acceptance or peace related to their illness, particularly in terms of physical changes and loss of functioning.

“It wasn’t passive ‘giving up,’ but rather an active coping process,” said first author Lori P. Montross-Thomas, PhD, assistant adjunct professor in the Department of Family Medicine and Public Health. “They emphasized how much they appreciated life, taking time to reflect. There was a keen sense of fully enjoying the time they had left and in doing so, finding the beauty in everyday life.”

“For all my life,” said one participant, “being a Southerner and having been in beauty contests, I got up in the morning, put my full makeup on and did my hair every day. A lady was never in her nightgown unless she was giving birth! Now all that is very, very difficult for me. … I’ve accepted it, and I’ve realized that I have to let it go. I have to ask for help and allow (others) to help me. I try to take all this with as much graciousness as possible. … and I’ve realized that my friends really don’t care that I don’t have makeup on or I’m in my nightgown. They are just happy to see me out of bed sitting on a chair.”

Patients also spoke of “galvanized growth,” said Jeste, adaptive characteristics “stimulated and forged by the difficulty of living with a terminal illness, such as greater determination, gratitude and positivity. The growth was linked directly to an increase in wisdom.”

Ultimately, Jeste said the hospice patients interviewed described wisdom as a continuous recalibration between actively accepting their illness and still wanting to grow and change as persons. The process see-sawed, they said. There was no static solution, but rather a constant effort to find balance, peace and joy at the end of life.

“Now, wisdom is being aware of my surroundings, trying to read the people that I meet, and trying to appreciate my day and look for the gifts. Look for the positive instead of the negative, I would say,” said one patient.

“I want them to remember me with a smile, laughing and giggling and doing some of the silly things we do,” said another patient. “You know, it is fun. Why do you want to leave on a sad note? I do not want to be remembered being sad.”

Co-authors include: Jamie Joseph and Emily C. Edmonds, both at UCSD; and Lawrence A. Palinkas, University of Southern California.

Funding for this research came, in part, from the National Institutes of Health (R25 MH071544), the National Institute of Mental Health (MH019934), the Stein Institute for Research on Aging; the American Cancer Society (MRSG-13-233-01-PCSM), the Westreich Foundation and the MAPI Research Trust.