Surrender at the End of Life

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First, the problem

“Do not go gentle into that good night…

Rage, rage against the dying of the light.”

So wrote the Welsh poet, Dylan Thomas.

Working intensively over the past seven years in end-of-life care, I have often seen this attitude as a response by good people to the bad things that are happening to them.  Our patients are faced with conditions that are terrible and despite our best efforts clinically are only going to get worse.  Faced with such, it is common for them to become angry and spend much energy fighting against their situation and much emotion in railing against their fate.  They spend their last days exhausting themselves in a futile struggle, burning up energy that might be better spent otherwise.

But, I have observed that some patients with mortal illness choose another way:  surrender.

What is surrender?

Last fall, I saw a woman in such a predicament. She had new focal seizures, difficulty speaking and unilateral weakness from brain metastases. The corticosteroid medication and brain radiation therapy helped improve her speech and movement only a little, and the anticonvulsant medications helped only to reduce, but not eliminate, the threat of more violent seizures.

At the end of my evaluation, I found myself talking with her about the concept of surrender.  She told me that she was not ready to give up. I said that surrender is not the same as “giving up,” but more akin to “giving in.”  I explained to her that surrender is the inner transition from resistance to acceptance, from “no” to “yes.”  I gave her several examples of how people have talked about surrender.

I asked this woman to try surrender as a response to her difficult situation, that is, to just go along with it for a little while to see what happened.  Later, I read her a poem by Jane Kenyon. Kenyon died of leukemia at age 45, after a bone marrow transplant failed her.  The poem beautifully evokes surrender as a response.

Let Evening Come

Let the light of late afternoon

shine through chinks in the barn, moving

up the bales as the sun moves down.

Let the cricket take up chafing

as a woman takes up her needles

and her yarn. Let evening come.

 

 Let dew collect on the hoe abandoned

in long grass. Let the stars appear

and the moon disclose her silver horn.

Let the fox go back to its sandy den.

Let the wind die down. Let the shed

go black inside. Let evening come.

 

To the bottle in the ditch, to the scoop

in the oats, to air in the lung

let evening come.

 

Let it come, as it will, and don’t

be afraid. God does not leave us

comfortless, so let evening come.

 

What characterizes surrender?

Dr. Elizabeth Kűbler-Ross in her book, On Death and Dying, defines several “stages” in patients’ coming to terms with mortal illness, including both anger and acceptance.

But surrender is greater than acceptance. It is an active volitional response, not a passive acquiescence. Surrender is not the same as submission. It is a choice.

Surrender implies something or someone to which one surrenders.

And it requires totality, a giving of oneself over wholly to something or someone else–giving, in T.S. Eliot’s phrase, “not less than everything.”

Surrender among the dying implies finality, irrevocability.

Finally, in surrender, there is vulnerability. But there is more than simple helplessness. In surrender, there is an element of anticipation, of giving oneself over to something, God, fate, the universe, mystery, and waiting to see what will happen next. Surrender is hopeful, or hope-filled.  There is promise, the promise spoken of by the Christian mystic Julien of Norwich, when she wrote, “All shall be well, and all shall be well, and all manner of thing shall be well.”

What does one surrender?

Three things, I think: there is surrender of understanding, surrender of control, and surrender of the “small s” self.

Surrender of understanding

Recently, I came across a wonderful little book called Stillness Speaks, by the spiritual master, Eckhart Tolle. It contains an intriguing chapter on dying and death, in which he writes about surrender.

Sometime, he says, surrender means giving up trying to understand and becoming comfortable with not knowing: “There are situations where all answers and explanations fail.  Life does not make sense anymore. Or someone in distress comes to you for help, and you don’t know what to do or say.”

But “when you fully accept that you don’t know, you give up struggling to find answers with the limited thinking mind, and that is when a greater intelligence can operate through you. And even thought can then benefit from that, since the greater intelligence can flow into it and inspire it.”

Tolle says, “Surrender comes when you no longer ask, ‘Why is this happening to me?’”

I think there is an analogy to meditation. In meditation practice, I often find myself distracted by thoughts and emotions and sensations. But there comes a point when I get to choose to stop paying attention to my own thoughts or to surrender. If I do surrender, then a remarkable thing sometimes happens. It is hard to describe.  “I” am no longer there. Where I am exactly, I don’t know. I am not asleep since I will transiently notice a noise or a breeze. Then, after a while, I return. I don’t know where I’ve been. But I do know that I am now in a very different frame of mind.  And if I go immediately to the wards, the conversations with patients and families are on a much deeper level.

Surrender of control

Patients who surrender, surrender control. Surrender of control means that one recognizes one’s powerlessness in the face of mortality. This is no mere acquiescence to the ultimate but an affirmation of it. 

Surrender of self

In the Judeo-Christian tradition, the Book of Job is a dramatic story of surrender of the “small s” self.

The philologist and scholar, Stephen Mitchell, has produced a remarkable translation of the Book of Job. He renders Job’s last words like this:

“I had heard of you with my ears;

but now my eyes have seen you.

Therefore I will be quiet,

comforted that I am dust.”

In his superb introduction to the translation, Mitchell says: “We need to notice that Job’s final words issue from surrender . . . the whole hearted giving-up of oneself.” And “once Job has learned to surrender, his world gives up the male compulsion to control. . . .His surrender is both the ultimate generosity and the ultimate poverty, because in it the giver becomes the gift.  He is no longer a servant, who fears God and avoids evil.  He has faced evil, has looked straight into its face and through it, into a vast wonder and love.  But instead of bursting into adoration, Job remains a hairsbreadth away from silence.  His final words are a miracle of tact.  We are not told the details of his realization; that isn’t necessary; everything is present in the serenity of his tone . . .”

To what or whom does one surrender?

Surrender to mystery

Nonreligious patients who are dying sometimes talk about surrender to mystery. Dr. Michael Kearney in his excellent book, Mortally Wounded, describes a Jungian psychological model of the surface mind and the deep mind. Surface mind is the domain of the ego, the “small s” self.  Deep mind is the domain of the spirit, the “large S” Self. The “deep center” is “what at the core of our being is ultimately unnamable, that which is deepest in us, the essence of who we are.”  Kearney’s book concerns the extreme case of patients who are literally dying in agony, in such pain that nothing we offer seems to help. He posits that such patients are in existential, rather than purely physical, pain. He describes a psychotherapeutic technique for helping these patients. “Healing,” he says, “comes through the patient choosing to descend from the surface to the deep, even though not knowing what will happen next.” 

Surrender to God

Other dying patients talk about surrender in frankly religious terms. I refer them to a little gem of a book entitled, Poverty of Spirit, by Johannes Metz. “We only find ourselves,” he says, “when we lose ourselves.”

“To be able to surrender oneself and become ‘poor’” he says, “is . . . to be with God, to find one’s hidden nature in God, in short, it is ‘heaven.’ To stick to oneself and to serve one’s own interests is to be damned, it is ‘hell.’”

About the dying process, Metz writes, “Man slips away from himself entirely. His . . . destiny is taken out of his grasp. In the obedient and suffering acceptance of these depths of powerlessness, man is left with only the power of self-abandonment.” But, “in abandoning himself to poverty, man abandons himself to God–whether he consciously realizes it or not. 

“How do you know when someone has surrendered?”

A student once asked me this question.

“Just by looking at him,” I replied.

All of us working in end-of-life care have witnessed the transformation that can follow a patient’s surrender.  Sometimes, observers mistake the profound change in attitude as one of resignation–of “giving up,” or as one of fatigue–“being too tired to fight anymore.”  But a look into the patient’s eyes is enough to know that surrender has occurred, and that it has transformed her.

In this, the dying–our dying, those you and I have loved and cared for–have much to teach us, the living.

Stephen McPhee, MD, recently retired as Professor of Medicine at the UCSF Medical Center. He was founder of the UCSF Palliative Care Center. This post is an edited version of three posts originally published on the Age with Spirit blog.

6 Responses to “Surrender at the End of Life”

  1. Steve Moffic

    Very beautiful and moving blog. Sometimes, I found in my practice, patients at the end of life tell us that they are ready to surrender. They seem to know when they are going to die and are at peace with it, and seem to want us to be at peace. And then they die. That was the case also with my own mother.
    A bit more complicated, I think, is the Buddhist surrendering to suffering. It is an acceptance of suffering as a necessary part of life, but not necessarily a desire to end that suffering, even with terminal illness.

    Steve Moffic

    • Carol Eblen

      Thank you for pointing out that that there are different religious beliefs about fighting or surrendering to death. It is instinctive for all healthy-minded individuals, no matter their age, to fight death if they believe that the quality of their life is “worth” fighting for, isn’t it?

      Therefore, why aren’t the “treating” physicians who are responsible for the educated diagnosis and prognosis of terminal patients responsible for educating the dying patients to their end of life choices and options under current law?

      It was the vision of the Medicare Hospice Entitlement that healthy-minded individuals would choose “surrender” in the Hospice setting and save $$$$$ for Medicare and the private insurers because they would die outside of expensive ICU and CCU hospital care.

      Why should patients have to surrender to “fiscal expediency?” for the physicians/hospitals or Medicare/private insurance if “medical futility” isn’t a factor?

      Do the bioethicists care that the patients are caught in the crossfire between Big Insurance and Big Medicine who fight for access to the Public Medicare Purse?

  2. Joan Paternoster

    Years ago I taught Family Health Nursing in a graduate program. Students worked with families coping with chronic and acute illness. The students had no trouble with acute conditions for that is the population with whom nurses generally work. The chronically ill present a different problem. Some patients and families spend a lot of time fighting the illness, trying to live as they did before the illness came into their lives. From my experience with chronically ill people and my physician husband who had CHF, I began to see that when families and individuals realized that they could not shut out the illness, accepted the illness and gave it a place in their lives they were less stressed. As one mother said about dealing with her child’s asthma, “I just decided to stop fighting it, and include it in all family plans. We are all going on with our loves and taking the asthma with us.
    Maybe this is also “surrender”.

  3. Laura Lee Carter aka the Midlife Crisis Queen

    The most profound and moving book I have read on this topic is Stephen Levine’s Healing into Life and Death… a life-changing experience for me!

  4. Lindsay

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