Broaching important conversations - about matters both concrete and sublime - is a necessary life-skill and one which unfortunately, few of us feel adequately tooled to undertake. In this section we will try to assist you with some basic mechanics; that is, we will try to help guide you through the discussion of issues that arise in the face of any serious illness.

In the case of a serious illness, whether our own or that of a loved one, opportunities (and necessities) for essential life conversations abound. Frequently we have choices to make about whether, how, and when we should, or should not, discuss personal, health, or family matters.

For someone newly diagnosed with a serious illness, even thinking about discussing the nuts and bolts of a will, living will, or power of attorney for health care can be overwhelming - especially considering the plethora of other decisions about treatment and care that are required, all in the space of a relatively short time, when likely as not, you are already reeling from receiving 'the news.' And yet, your physician, hospital, and clinic will all be asking for clarifying information on these issues and so many more.

For those who have 'settled in,' however reluctantly, to treatment (either short-term or long-term) for such an illness, a whole variety of other decisions come to the fore. And at every turn, it seems, more 'discussions-in-the waiting' are lining up - conversations that need to occur, but oftentimes do not. It can feel uncomfortable or just plain rude to broach some subjects of consequence, including discussions of 'What should we do if?' or 'I just want you to know that...'

For those whose life-span is significantly limited by illness, the discussions-in-the-waiting take on a more urgent hue. Conversations towards the end of life, about matters of faith and love, forgiveness and reconciliation, are so essential, and yet so difficult to embark on.

The truth is, like most things, these issues are best discussed earlier rather than later. And they are best discussed in an environment that is conducive to helpful discussion and in the presence of those who can help to facilitate the discussion to a positive end.

Ground Rule # 1: Safety First.

Be smart. Be safe: The rule of thumb for all important personal and family discussions is that every person involved needs to feel safe - both physically and psychologically. If either physical or psychic safety is a concern, then it is best to seek professional help, or not to embark on the discussion. Do not attempt a discussion of consequence within an unsafe-feeling environment or with people who are likely to be emotionally or physically volatile or abusive.

Helpful Tool: First, discern if the conversation is indeed essential, and, if so, who would best be involved in it - or not involved in it. If safety is still a concern, then ask your physician or other health care provider or your pastor for a referral to counseling or for help in arranging a family conference attended by or facilitated by a social worker, pastoral care staff person, or other health care professional.

Ground Rule # 2: Discern topics and dynamics.

Discern the appropriate topic: Is this topic important? Timely? Essential? Is the outcome of this discussion important to me? To my health? To my family or friends? Is it something I need to address immediately, or can it wait?

For instance, for a person undergoing chemotherapy or radiation treatments, the topic might be what is or isn't helpful. For one person, the concern might be: "I know my friends want to help, and I really appreciate all the offers of delivering dinner, child-care, and house-cleaning. And it's great that all my friends and family want to be updated on how I'm doing. But I am so exhausted, I can't even talk to them, much less return phone calls or write thank-you notes. It sure would be easier if a few of my close friends coordinated the communication and delivered the food - or just picked up the kids for an afternoon. Or let me rest while they clean up the house. Or drove me to my treatments. I'm pretty much only comfortable with family and close friends seeing me so wiped out."

For another person, the conversation might sound something like this: "Mom, (or daughter) I know how much you love me, and I appreciate your help more than I can say. But occasionally I just need some time alone. Focusing on or talking about my illness so frequently makes me feel more anxious. Maybe we can work out a system of care that allows you to help, without me feeling increased stress: a plan that works for both of us."

Helpful tool: Be sure to craft the topic so that it is not so large as to be overwhelming, or so small as to be inconsequential. For sensitive subjects, or those with significant consequences, it's sometimes best to choose an ongoing discussion, or divide the topic into smaller, more manageable segments. (Or to seek professional assistance with facilitation.) Also, since a serious illness can bring so many subjects of import to the surface, it might be best to prioritize which subjects might best to attend to first, and which might be acceptably postponed to a later time.

Discern the dynamic: Is the dynamic between those who will be discussing the issue likely to help the discussion? Or hinder it? Make an honest assessment of who should be involved in a discussion and what the interpersonal dynamics might be.

Differences in gender and personality should be taken into account. It is a given that some people tend to be more emotionally focused, while others might be more comfortable homing in on the practical implications of a problem. Some people see issues in a more linear fashion, while others might be more integrative in approach. Clearly, some people talk more and others excel at listening.

No matter.

Everyone at the table - be they mothers, fathers, sisters, brothers, aunts, uncles, cousins, neighbors, or friends - will bring their own unique perspective to bear on the discussion at hand. And that is good, though it may not always be easy.

Helpful tool: An essential conversation is just that: essential. So don't let differences in communication styles or personalities stop you. Just take the differences into account, decide to respect one another, and choose to move forward.

Ground Rule #3: Start the process. Follow through.

Many times, the most difficult part of having an essential conversation is actually deciding to try it. And many, many times, that is where the conversation gets stuck. It may be helpful to discern, to pray, and then to make a commitment that you will really follow through on at least beginning the discussion.

Many people think: "I'd really love to discuss that with Mom or Dad; I hope we get the chance."

Or, "I really need to know what my spouse would prefer in terms of funeral plans or end-of-life care, but I feel uncomfortable bringing it up. I'd hate for him to loose hope."

Or, "Some of my loved ones don't seem to understand how serious this illness is. Every time I try to bring up the subject of me getting worse, they deny it, or change the subject. I wish I could figure out how to talk to them about all this, because it sure feels lonely to worry about all of it by myself."

Too often, the discussions we would most like to have with our loved ones never happen - and it's not because we don't want them to. It's just that life, especially life with a serious illness, can be so busy, and the pace so hectic and so tiring, that we never seem to have either the time or the energy to bring up the issues closest to our hearts.

Plus, we just don't know how, or what, to say. And some things seem easier to avoid than to deal with, especially in the midst of tough times. Or perhaps, we think there'll be time later, only later rarely comes - and not because some people with a serious illness don't recover. Many people certainly do.

It's just a fact of human nature that we are generally more comfortable postponing for tomorrow what might be best and more effectively done today. In the case of an unexpected death, putting off essential conversations until too late can complicate survivors' grief and have lasting effects.

Helpful tool: Make a time-line, or at least establish a general idea of when you'd like to begin the discussion. Write down a few possible ways in which you can imagine bringing the subject up. Remember, it is very, very difficult to put to rest unresolved relationship issues after a loved one has died. And it really is not a matter of "if." We will all die, eventually, whether of this illness or some other. So begin the process of speaking and listening with heart. Follow through. Get started on those essential conversations.

Ground Rule # 4: Leave the baggage behind. Begin anew.

An essential conversation is not a 'baggage claim.' So resist the temptation to continually re-visit past wrongs, especially in the midst a meeting where several family members are gathered, attempting to problem-solve.

Check that old luggage at the door. In so far as you can, leave the baggage from past conflicts in the past. Focus on the present.

What needs to be communicated? To whom? How? And when?

The following examples are obviously tongue-in-cheek conversational caricatures that have been exaggerated, and yet possibly have a glint of truth.

Clearly, while attempting to organize home care and family-based assistance for an elderly relative who has recently fallen and broken a hip, it may not be helpful to let loose with the following: "This issue has been bugging me for years. I've been waiting a long time to lay it all on the line, to tell Great Uncle Alvin what I really think of him - that great big oaf! And Great Aunt Matilda. That persnickety busybody. I'm gonna have an 'essential conversation' with her, I can tell you...Let me at her!"

Needless to say, that might not be the most diplomatic of conversation starters.

Nor would the following: "No way am I talking to Mick. I haven't spoken a word to that dirtball since he borrowed my lawn mower and broke it 15 years, 2 months, 3 days, and 6 hours ago. And no way I'm talking to him now, essential family conversation or no."

Humor aside, the truth is that leaving old family baggage behind can be pretty challenging.

It takes enormous effort not to allow the conversation to get mired in past wrongs, disagreements, or hurts. (On occasion, in a one-to-one facilitated conversation where the focus is on forgiveness or restitution of past wrongs, bringing up past hurts may be a necessary means for healing and recovery.)

Helpful tool: Because we are all human, we are all broken - every single one of us. And in need of redemption. At any given time, any one of us could recite a litany of hurts drawn from a lifetime of misunderstandings. But most of the time it's simply best to take a deep breath, focus on the problem at hand, and work together to create a cogent solution. Cut one another a huge slice of slack. This is not to say it is easy. But it can be done, with courage, generosity of heart, and a relentless focus on seeking, and doing, the good beyond ourselves.

Ground Rule # 5: Be kind; Listen well.

Approach the conversation with kind intent - and with a listening heart. Most people can tell when a person is speaking from love or acting out of frustration or a from a need to control. Try, in all things, to be love-based.

You know already that to be 'love-based' is not always easy, especially in situations where family members or friends are 'scratching on our psychic blackboards,' or generally bugging us (perhaps in the same way that they've been bugging us for what seems like a hundred years!). God knows, (and He does know!) it may be next-to-impossible to act with kind intent and a listening heart towards those who criticize or belittle us.

In fact, to "love one another as I have loved you," has never been easy.

Luckily, you have help. You have only to "ask and you shall receive, seek and you shall find, knock and it shall be opened to you."

Try not to forget: the good Lord loves you. He will give you the strength you need to get through each day. If you ask for his consoling grace, he will provide you with the strength you need to be charitable, even to those with whom you disagree.

Attentive listening can also be a challenge, even in the best of relationships. Add stress, illness, and intense emotions, and listening is harder still. But try to make the commitment to really, truly listen, to listen to one another with open hearts and minds, even if you disagree with the stated opinions. Disagreements tend to be far less intense, and essential conversations work out far better in the long run, when people feel they are being listened to.

Helpful tools: Be kind. Listen attentively. Dilute disagreements with love.

Ground Rule # 6: Be prepared. Play your instruments. Let the music begin!

You may well be surprised, once you get started, how natural discussions of essence can become. You should plan to start simply, then build ongoing discussions. You might also be surprised how easy it is to continue, once you get the courage to begin.

One simple way to start is: "Mom, I've been thinking about____________, and I wonder if it would be all right if we talked about it? Now would be a good time for me. Is this an OK time for you?"

Or, "Mabel, we've been friends for a long time. You know how much I love and respect you. But I have some concerns I'd like to share with you. I'm worried about your safety. It seems like now might be a good time for you to consider getting some household help with cooking or cleaning, or gardening. At some point, you may even want to consider the pros and cons of moving to a residential care facility or getting some home health assistance at home...I would sure hate to see you get hurt."

Be forewarned, no ground rule can assure the discussion outcome you desire. In fallible human communication, there really are no 'sure things.' But, as the old saying goes: 'nothing ventured, nothing gained.'

It may be helpful to remember that you are only responsible for practicing the musical score, for playing your own instrument according to the ground rules, for trying your very best. In the end, the discussion's resulting sound may be more akin to a child's discordant 'harmonizing' than one of Mozart's masterpieces.

That's OK. As anyone who has ever listened to the symphonies of childhood knows, what appears to be disharmonic might actually be the very best a person can do under the circumstances. And that, after all, is the most any of us can ever be responsible for.

You should also know that it is not uncommon to have to repeat a particular essential conversation more than once. Both teachers and marketing experts agree on one thing: that a person has to have a 'readiness to learn' for change to occur. And we humans are notoriously resistant to change.

In practice, that sometimes means that we don't change until or unless we have to. Great Aunt Matilda may have been warned for years by her family that she needed extra help and that she was at risk for falling and breaking a hip, but most likely she just plain wasn't ready to listen. Ditto for Mabel above. All you can do is try. And try again.

If you have a similar circumstance in your family, do your best to effect a change, but know that in the end, you may not be able to make someone 'see sense' in the way you wish they would. Alas, wherever you go, there we are: the humans, with all our foibles, quirks, irritations and vulnerabilities. And blessings. Along with fragile glory.

Be aware that though practice doesn't necessarily make perfect, it sure does make for a better-sounding symphony, one in which the players are working with one another, as opposed to against one another, playing off the same score. And leaving a musical legacy of truthfulness and grace.

Helpful tool: Seize the day. Compose that family love symphony. Today. Play it tomorrow. Be sure to 'seize the day' in a gentle, loving, and straightforward fashion. Then work through the difficulties as they arise. Carpe diem. And may God bless you.

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Next page: Chapter 6: Medical Decision Making: Making your wishes known: An Overview: Guiding families through important decisions