Every one of us receives and passes on an inheritance. The inheritance may not be an accumulation of earthly possessions or acquired riches, but whether we realize it or not, our choices, words, actions and values will impact someone and form the heritage we hand down. — Ben Hardesty

There is a growing body of evidence that clinical interventions that enhance the spiritual well-being and a greater sense of meaning in patients with advanced cancer have a number of significant benefits (Brady, Peterman, Fitchett, Mo, and Cella, 1999; Breitbart, Gibson, Poppito, and Berg, 2004). These benefits include:

• Reduction in anxiety,
• Reduced sense of isolation,
• Greater ability to tolerate severe physical symptoms,
• Higher satisfaction with quality of life,
• Decreased feelings of hopelessness and desire for death (independent from variable of depression) and
• Decreased rates of despair and major depression.

Given this evidence, as well as countless anecdotal accounts of the impact of attending to the pursuit of a life of meaning and purpose, oncology social workers and other clinicians who work with patients living with life-threatening illness may find it beneficial to learn about and incorporate interventions that attend to these dimensions of their patients’ lives. These interventions may include, but are not limited to, existential psychotherapy (Fischer, 1982; Yalom, 1980), dignity-based therapy (Chochinov, Hack, Hassard, Kristjanson, McClement, & Harlos, 2005; Chochinov, Kristjanson, Breitbart, McClement, Hack, Hassard, & Harlos, 2011), spiritually-integrated psychotherapy (Pargament, 2007; Pargament, Murray-Swank, & Tarakeshwar, 2005), individual meaning-centered psychotherapy (Breitbart et al., 2004; Breitbart, Poppito, Rosenfeld, Vickers, Li, Abbey…Caassileth, 2012), and meaning-centered group psychotherapy (Breitbart, Rosenfeld, Pessin, Applebaum, Kulikowski, & Lichtenthal, 2015).

While it is ideal for clinicians to pursue study, training and ongoing clinical supervision in these modalities, it is also possible to incorporate elements of these interventions into one’s everyday work with clients. Examples include utilizing meaning-focused reflecting questions during assessments and counseling sessions or helping a client create a work of legacy. Ethical wills are one such type of legacy project.

The ethical will originated as a Jewish tradition dating back over two millennia. It is a written statement from a parent, teacher or relative that attempts to put into words the lessons learned and the values lived by during his or her lifetime, with the hope of passing this type of life legacy on to their children, students and future generations. Ethical wills include the communication of values, beliefs, hopes, personal philosophy, life lessons, blessings, regrets and forgiveness.

In recent years, I have had the privilege of helping several people complete their ethical wills. An invaluable resource in this endeavor is Barry Baines’ book, Ethical Wills: Putting Your Values on Paper (2006). Baines suggests completing the following exercise before beginning to write (p. 16):

• "Write down the name of a deceased relative whom you may have heard stories or “legends” about when you were growing up. Imagine that you could go back in time to talk to this person. What questions would you like to ask them? What would you want to know about their lives and their values, what they hoped to pass on to future generations?  
   
• Next, consider the future: 75-100 years from the present day. Imagine one of your future family or community members doing this same exercise and selecting you. Consider that many of the events that we consider “ordinary” or not very interesting in our day-to-day lives will be quite fascinating 75-100 years from now, particularly to those who feel some sense of connection to us through family, geography, chosen profession, or other link.”

I’ve found this exercise particularly valuable for clients who view themselves as “uninteresting” or leading “boring and ordinary lives.” This is also a clinical opportunity to gently challenge that notion and to help clients view themselves through a new lens.

Although every ethical will is unique, they tend to share some common elements and themes. A typical format includes:

1. A greeting and some opening thoughts,
2. Statements of values and beliefs,
3. Special memories & meaningful life lessons learned,
4. Hopes for the future (for oneself and/or one’s loved ones) and
5. Closing thoughts.

Many times, it is easiest for people to get started once they have a greeting on the paper—in fact, I often suggest that people liken this to writing a letter, as this is essentially what they are doing. It is also important to help people release concerns about their writing abilities or style. This process is about content, not style or grammar, neither of which will matter to family or future descendants who may read it one day. What IS important is to be genuine and heartfelt, so that the ethical will reflects who the writer is, including their cherished memories, their beliefs and deepest values.   

As therapists, we are skilled at asking questions that help our clients “dig deep.” We can help our clients to explore the themes that matter most to them through this process. Some of the questions below are ones that may be helpful in shaping an ethical will and, incidentally, are similar to those utilized in the interventions mentioned (e.g., MCP, dignity therapy, etc.).

• What do you value most in life?
• Do you have any spiritual, religious or philosophical beliefs that are important in your life? How are these helpful to you?
• What have you done in your life to embody or to stand up for your beliefs?
• What are you grateful for at this time in your life?
• What is one of the best pieces of advice anyone ever gave you?
• How would you describe your philosophy for facing life’s difficulties? What has been a source of strength for you during difficult times?
• What have you learned at this phase of your life that you wish you could have imparted to your younger self?  
• What are your hopes and dreams for your loved ones?
• What would you especially like your loved ones to know and remember about you?

Assisting a client to explore these themes will inevitably lead to many rich clinical opportunities to facilitate healing and growth. There will also be the opportunity to witness and support your client through anticipatory grief, which may arise throughout the process, but often particularly when working on the conclusion of the ethical will. While the conclusion is usually a simple statement or paragraph, the writing of it often serves as an opportunity to practice “goodbye work.” Consider the following prompts:

• I am so thankful for all those who have been good to me. I have lived a good life. I wish a good life for each of you…..
• My love will always be with you, and I want you to know….
• You have all been such a great source of joy for me. I love you very much and am grateful….

Once your client has completed the writing of his or her ethical will, the next step is to share it. In addition to any electronic copies, it is also advisable to maintain a hard copy on archival (acid-free) quality paper and store it in a folder that is made of archival quality materials. Some people choose to attach their ethical will to their legal will. Many choose, however, to share their ethical wills while they are still living, which creates profound opportunities for ongoing and deep conversations with the recipients, and allows for additions and revisions to the ethical will over time. Ethical wills may also be read at funeral and memorial services, and can provide content for eulogies.

Some oncology social workers may be in a role where they do not have the time to conduct this intervention. In this case, I would suggest that there is value in simply suggesting the activity and citing and/or making available books that can help the client to create an ethical will.

References

Baines, B. (2006). Ethical wills: Putting your values on paper (2^nd ed). Boston: Da Capo Press.

Brady, M., Peterman, A., Fitchett, G., Mo, M., & Cella, D. (1999). A case for including spirituality in quality of life measurement in oncology. Psychooncology, 8, 417-428.

Breitbart, W., Gibson, C., Poppito, S., & Berg, A. (2004). Psychotherapeutic interventions at the end of life: A focus on meaning and spirituality. Canadian Journal of Psychiatry, 49, 366-372.

Breitbart, W., Poppito, S., Rosenfeld, B., Vickers, A., Li, Y., Abbey, J. Cassileth, B. (2012). Pilot randomized controlled trial of individual meaning-centered psychotherapy for patients with advanced cancer. Journal of Clinical Oncology, 30, 1304-1309.

Breitbart, W., Rosenfeld, B., Pessin, H., Applebaum, A., Kulikowski, J., & Lichtenthal, W. (2015) Meaning-centered group psychotherapy: An effective intervention for improving psychological well-being in patients with advanced cancer. Journal of Clinical Oncology, 33, 749-755.

Chochinov, H., Hack, T., Hassard, T., Kristjanson, L., McClement, S., & Harlos, M. (2005). Dignity therapy: A novel psychotherapeutic intervention for patients near the end of life. Journal of Clinical Oncology, 23, 5520-5525.

Chochinov, H., Kristjanson, L., Breitbart, W., McClement, S., Hack, T., Hassard, T., & Harlos, M. (2011). Effect of dignity therapy on distress and end-of-Life experience in terminally ill patients: A randomized controlled study. The Lancet Oncology, 12, 753-762.

Fischer, C. (1982). Existential therapy. In G. Corey, Editor, Theory and practice of counseling and psychotherapy (2^nd ed., pp. 67-75).) San Francisco: Brooks/Cole Publishing.

Pargament, K., Murray-Swank, N., & Tarakeshwar, N. (2005). An empirically-based rationale for a spiritually-integrated psychotherapy. Mental Health, Religion & Culture, 8, 155-165.

Pargament, K. (2007). Spiritually integrated psychotherapy: Understanding and addressing the sacred. New York: The Guilford Press.

Yalom, I. (1980). Existential psychotherapy. New York: Basic Books.