A Coaching Approach to End-of-Life Discussions

“I’m sorry to say so
but, sadly, it’s true
that Bang-ups
and Hang-ups
can happen to you.

You can get all hung up
in a prickle-ly perch.
And your gang will fly on.
You’ll be left in a Lurch.

You’ll come down from the Lurch
with an unpleasant bump.
And the chance are, then,
that you’ll be in as lump.

And when you’re in as lump,
you’re not in for much fun.
Un-slumping yourself
is not easily done.”

Understanding End-of-Life Coaching: What Is It and How Does It Help?

This excerpt from ‘Oh, the places you’ll go’ by Dr. Seuss^[1] can be a simplistic metaphor for how someone may feel when faced with a life-limiting diagnosis. Although in reality, such a diagnosis may be complex, devastating, incomprehensible, frightening, confusing and so much more, having the love, support and guidance of families, loved ones and a range of professionals, can go some way to easing the burden.

The Role of End-of-Life Coaches in Difficult Conversations

Those of us who have the privilege of working to provide that end-of-life support as end-of-life or death doulas (or similar) generally have one goal in mind – to offer non-medical, holistic support as we accompany our clients on this journey.

A Coaching Approach vs. Traditional End-of-Life Care

Although trained as an end-of-life doula and offering the usual services and support provided by that role, as an accredited and experienced conflict coach and resilience coach, and with post-graduate qualifications in ontological coaching, I call myself an end-of-life coach. The word doula, of Greek origin, meaning ‘woman servant or caregiver’, is not a good fit for me personally. Regardless of the name used, we all enable our clients to make their own choices and decisions whilst being supported, informed, listened to, and valued. So why a coaching approach?

“Good coaches believe that individuals have the answer to their own problems, whilst understanding that they may need help to find the answer. In his book ‘The Inner Game of Tennis’, Timothy Gallwey suggested that the biggest obstacles to success and achieving potential as a tennis player were internal, not external. His insight was that coaches could help individuals to improve their game by distracting them from their inner dialogue. By distracting the inner voice, the body could take over. It turns out that the body has a very clear idea of what to do when internal dialogues are suppressed. Gallwey’s real insight was this didn’t just apply to tennis, but that individuals generally did have the answers to their own problems within themselves. The essential part of coaching then, is to help people learn to silence that inner voice and allow their instincts, or their subconscious to take over. Sometimes that means distracting it, and sometimes it’s about exploring the ‘worst case scenario’ and removing the fear”.^[2]

Becky Placko Brotemarkle, a US based health and wellness coach has a similar philosophy. She states that “end-of-life coaching is about being with people who are dying and those who are grieving using a coach approach. As an End-of-Life Coach, I recognize the person (the one who is dying, the one who has had a life loss, or the one who is grieving) as the expert in their life. In the coaching sessions, a ‘safe space’ is created where you can share openly without worry. I'll ask powerful questions, ones that are from listening deeply and invite you to look inside where you have answers that are hidden and you haven't acknowledged. I'll walk next to you to affirm the normalcy of the process you are going through without offering advice or assuming I know what's right for you or trying to fix you. Using the coach approach, I'll honor your wisdom and explore ways for you to live from that place. Transformation occurs when you are seen and heard in this deep way.”^[3]

Using Ontology in End-of-Life Coaching: An Overview

Although there are many coaching frameworks in use, my practice as an end-of-life coach is informed by the philosophy of ontology. “Ontology is the study of being, in particular the investigation of the nature of human existence.”^[4]

“In ontological coaching, the dynamic interplay between language, emotions and body is referred to as the Way of Being. The essential goal of the coach is to be a catalyst for change by respectfully and constructively triggering a shift in the coachee’s way of being, to enable him or her to develop perceptions and behaviours that were previously unavailable………a critical task for the coach is to create a safe environment for inquiry, learning and discovery through a deeply respectful relationship with the coachee. This means regarding the coachee as a legitimate other. Two challenges in maintaining a safe environment are (i) respectfully initiating a different and potentially sensitive direction in the conversation; and (ii) the coach not being too attached to his or her ideas of where the conversation should go.”^[5] Ontological coaches work through the three domains of language, emotion, and body.

Helping Clients Overcome Fears and Anxiety at the End of Life

When coaching in the domain of emotion, we frequently consider some basic moods of life. One of our goals is to support the coachee to move to a place of acceptance from a place of opposition. Three examples are:

1. Facticity – what we assess as unchangeable. This is the mood of resentment, and it may be that we can’t get past something and this can manifest as hostility or active and passive aggression. Transitioning to a mood of peace may involve coming to terms with the situation and feeling OK.
2. Possibility – what we assess as changeable. This is the mood of resignation. We may hear, ‘it will never work’, ‘I’ve tried that before’, ‘Here we go again’. By transitioning to a mood of ambition we may hear ‘let’s go for it’, or ‘how can we make this happen’.
3. Uncertainty – what we cannot confidently predict. This is the mood of anxiety and can manifest as confusion, fear and doom. Transitioning to a mood of wonder may elicit statements such as ‘what if’, ‘I wonder what would happen if’, and ‘wow’.

So, for me, taking a coaching approach to my conversations assists me to achieve a number of outcomes for my clients:

Supporting Clients and Families Through End-of-Life Coaching

• That they feel listened to and are more able to make choices that align with their values, life-experience and gut-feeling.
• That they can explore and identify their learned behaviours when dealing with change and adversity. Those who are change resilient and typically frame challenges as opportunities will manage end-of-life challenges differently. Understanding this ensures the conversations and choices align with their capacity to take helpful actions.
• That they understand the dynamics that exist within their family and friendship circles – how communication usually occurs and who may be more open or closed to having difficult conversations, controlling conversations, and/or closing them down.

Effective Communication Strategies During End-of-Life Discussions

• That they can reflect on what is important to communicate and in which order of priority. Many of us can only process difficult news in bite-size chunks. Sharing everything at once can be overwhelming to all parties, and once bad news is delivered, it is likely that things said afterwards may be missed or misconstrued.

How To Handle Pushbacks in End-of-Life Conversations

• That they have strategies to deal with pushbacks and are able to understand why those occur. People often say that when they want to talk about matters related to death and dying a common response is, ‘don’t be morbid’, or ‘I don’t want to talk about that’, or similar. Being prepared to respond to pushbacks in a respectful way is critical, as is understanding that pushbacks often occur because of the other person’s fears about their own mortality.
• That they can start to break down the issues they are facing and decisions that they need to make in a manageable way. Feeling angry, scared, incredulous and so on may retard the ability to be logical and maintain perspective.

Exploring Choices and Regrets: A Personalised End-of-Life Journey

• That they can reflect on more existential issues as well as the more immediate and practical. Regret is a common theme, and sometimes it is regret about loss of a friendship or relationship that they may wish to re-kindle. If this is at all possible i.e. the person is still alive and contactable, it is critical to understand the reasons for the breakdown of the relationship, and to reflect on how each person may have experienced it and how much accountability they may wish to take for their role in it. Whereas once you may have had no interest in re-connecting, once diagnosed with a life-limiting illness, your perspective and priorities may well shift. Such matters can be complex and being prepared for the possibility that the desire to reconnect may not be mutual, can be challenging in an already difficult space.

Creating Safe Spaces For End-of-Life Conversations

• That they understand that it is their own end-of-life journey. Although how that journey evolves should align with their wishes and needs, death is a collective experience. Juggling self-need and considering the impact of death on those left behind can be complex. Mourning and grief can be impacted significantly by the choices made and the behaviours lived during the person’s end-of-life journey. Finding the sweet spot, when indeed possible, requires reflection, courage, discussion, planning, and the ability to compromise and adapt.

‍

_{[1] Seuss, 2003, Oh, The Places You’ll Go, Harper Collins Publishers, London UK
[2] https://www.skillsyouneed.com/learn/coaching.html
[3] https://www.macrolifecoaching.com/general-6
[4] Honderich, T. (Ed). 1995. The Oxford companion to philosophy. Oxford University Press, Oxford UK
[5] Sieler, A. 2003/2007. Coaching to the Human Soul: Ontological Coaching and Deep Change, Vols, I/II. Newfield Australia. Melbourne}