“I don’t want to give up,” expressed a heroic 52-Year-old woman who had been battling aggressive metastatic breast cancer for three agonizing years. At one point, Natalie had almost achieved the insurmountable feat of remission, but then the cancer returned with a vengeance. Natalie arrived at the crossroads of a decision point in the emergency department. The traditional chemotherapy had been exhausted and her current homeopathic treatment was triggering excruciating headaches. Her ensuing course of action presented the ultimate challenge – a change of heart.

Appropriate treatment in the ED included IV fluids, lab studies, and pain medication. Natalie was able to rest comfortably while the physician deliberated her ongoing treatment and disposition from the ED. Was it best for her to be admitted to the hospital or for her to return home? Was she open to having a heart-to-heart conversation or would she remain focused on achieving remission? While “I don’t want to give up” was heard loud and clear, this was only one side of the conversation. Natalie provided the additional insight that she had refused to be part of an investigational study and presumably wished to be treated with dignity.

The physician’s treatment plan needed to include an empowering discussion regarding good conscience that includes listening to both her devil’s advocate and her guardian angel. While her devil’s advocate insisted on always thinking positively, her guardian angel was requesting Natalie be good to herself. The dubious resolution to her unrelenting headaches and internal conflict rested solely on Natalie’s shoulders and aligned with higher consciousness. Would she err on the side of hoping to prolong her life indefinitely or on living in the light of a peaceful surrender?

While Natalie was aware of palliative care, unfortunately this resource carried a negative connotation and direct correlation with hospice care. It became necessary for her physician to clarify that palliative care does not equate to end-of-life care, but is the bridge between advance care and hospice care. Palliative care allows patients peace of mind and free choice between medical intervention in the hospital and medical care at home. This decision-making process requires both orderly and critical thinking, realizing a clear understanding of one’s own medical condition, medical prognosis, quality of life, personal wishes and good conscience.

When patients are hell-bent on prolonging life at all cost, quality of life and quality of death (dying with dignity) often evades these patients. Good conscience is a spiritual guide that includes awareness of a time to every purpose amid the circle of life. The Universal Healthcare Directive provides for the time to be born, the time to live, the time to survive and the time to die with preventive care, advance care, palliative care and omega care accessible during each time, respectively. Omega care is profound end-of-life care that individuals choose proactively and wholeheartedly, while hospice care is often seen as a consolation prize for patients who lose their battles. Aligned with the Universal Healthcare Directive are the abiding virtues of faith, hope and love.

Even though Natalie was not officially enrolled in palliative care, she was appropriately provided the free choice of remaining in the hospital or returning home. Having experienced pain relief and given permission to be freed from the condemnation of giving up, she was eager to return home. She had even considered the prospect of truly returning home to Lake Powell in Northern Arizona. Natalie and her husband had reluctantly relocated to Phoenix, Arizona for her intensive cancer treatment. Phoenix had been the appropriate place for her to rise from the ashes during the time to survive. Lake Powell would be the perfect dwelling for her to abide in grace during her final days.

Graceful Departures is imagined as the vacation destination of a lifetime; a safe haven from the compulsion inherent to false hope and the obligation often imposed by caregivers. Along with this gift of receiving a little heaven on earth, joyful bliss arises from a sense of accomplishment and celebratory outburst, “I made it!” The end of life is often believed to be God-awful rather than perceived as being called home by God. In this moment of surrender, a person has the choice of taking his own life, becoming massacred or going into exile. Graceful Departures promotes this exile as an uplifting outlook and nurturing experience of one’s creation. A type of personalized Promised Land where amenities and tranquility abound. Each Advance Care Directive needs to endorse Graceful Departures as the ultimate rite of passage for dying with dignity.

No longer will the end of life be treated as a medical condition – it is a spiritual destination. Birth of a human being is considered to be a gift from God. Similarly, death may be considered the return of this gift to God. Many people leave this world feeling maligned and forsaken by the very healthcare system that supposedly seeks to improve their well-being. This system specializes in scientific research and treatment, yet it appears inept in the art of spiritual healing. Physicians may know how to counsel a patient, but rarely understand what it means to console a patient.

Consoling patients aligns with granting them three wishes – certainty, choice and comfort. Natalie was provided certainty in that her oncologist was not saving the best chemotherapy for last. She had received the best possible care upfront and she could proudly claim victory in surviving longer than most. Her choice was limited through not receiving palliative care prior to this last ditch conundrum in the ED. Comfort was bestowed by the physician providing her a change of heart, suggesting that she listen to the higher conscience of her guardian angel. Lovingly, this guiding messenger led her through the befuddled network of best standard practice to the peaceful, easy passage of Graceful Departures.

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