When we recognize that we don't have all the time in the world, we see our priorities most clearly.
—Laura Carstensen
Montross-Thomas and colleagues begin their article “Reflections on wisdom at the end of life: qualitative study of hospice patients aged 58–97 years” with a quote from Kierkegaard on the paradox of being able to only reflect on life while continuing to live each day (Kierkegaard, Reference Kierkegaard1843). The quote supplied above from Carstensen (Reference Carstensen2011) builds on this idea, suggesting that knowing that one is in the final portion of one's life can sharpen priorities and goals. Carstensen's work on future time perspective (Lang and Carstensen, Reference Lang and Carstensen2002), in the context of her theory of socioemotional selectivity (Carstensen et al., Reference Carstensen, Fung and Charles2003), dovetails well with Montross-Thomas et al.’s findings on the reflections of 21 hospice patients at the end of their life. Although the context of their study was how such patients might find their perceptions of wisdom shaped by the fact of their terminal illness, the patients in this study reported that part of their challenge was to balance accepting their current circumstances, including a foreshortened future, while still striving for growth and meaning.
The participants in the current study responded to a small set of open-ended questions, which were analyzed qualitatively using a grounded theory approach. The two questions of particular relevance with respect to wisdom and the end of life were “What experiences have influenced your level of wisdom?” and “How has your illness affected your level of wisdom?” The majority of patients in the study were Caucasian (81%), male (57%), Christian (48%), and diagnosed with cancer (48%). In terms of age, the range was 58 to 97 years, with a mean age of 78 years. It is important to keep these demographics in mind when interpreting these findings, as both views of wisdom and other theories such as Carstensen's socioemotional selectivity theory have been shown to differ across cultures (e.g. Fung et al., Reference Fung, Stoeber, Yeung and Lang2008). Indeed, Montross-Thomas et al. comment on the variation in conceptualizations of wisdom being dependent on factors including, for example, age, cohort, culture, and philosophical lens. And through their work, they aimed to establish whether a factor such as experiencing a terminal illness might similarly contribute to the conceptualization of wisdom.
The themes that emerge from these patients’ reflections on wisdom align well with available conceptualizations of wisdom, including the work of Bangen et al., which the authors describe in their introduction. This is unsurprising given that in the main, the Bangen et al. meta-review focused primarily on research utilizing participants culturally more like those captured within the Montross-Thomas et al. research. Takahashi and Bordia (Reference Takahashi and Bordia2000) are one of the few who have considered wisdom and culture more specifically, comparing the interpretation of wisdom by those from a Western culture with those from an Eastern culture. Results indicated more of a focus on knowledge and experience in the Western culture, while in the Eastern culture, the focus was more on aging. The examination of cultural influences remains an underdeveloped area within the wisdom literature; studies such as that of Takahashi and Bordia (Reference Takahashi and Bordia2000) highlight the impact that various factors (such as culture) can have on how wisdom is conceptualized.
In addition to capturing the more common themes identified in the wisdom literature to date, Montross-Thomas et al. also capture one of the conundrums of the construct of wisdom, whereby individuals have their own understanding of what wisdom is, and in doing so, interpret their level of wisdom within that conceptualization. In comparison to the Bangen et al. meta-review, Montross-Thomas et al. found that terminally ill patients place similarly high importance on the wisdom themes of prosocial attitudes, behaviors, and decision making. However, the patients also ranked emotional regulation (ranked fifth in the Bangen et al. paper) and openness to new experience (ranked seventh in the Bangen et al. paper) as higher in importance. Reflection and self-understanding and value relativism and tolerance were ranked lowest, while in the Bangen et al. meta-review, the former component was ranked third overall and the latter ranked sixth. Therefore, the link between Carstenson's socioemotional selectivity theory is appropriate, with more consideration given to meaningful social ties, to the sharing of self with others, and a greater appreciation of what is left in life by those experiencing a terminal illness. This is then reflected in what participants see as the most pertinent elements of wisdom, namely those more focused on the meaningful social elements of their lives.
Of course, it is normal research practice to aim to compartmentalize and make qualitative data more meaningful by grouping it into themes. And so, a refreshing element of Montross-Thomas et al.’s work is that they also look to consider the unique insights offered by this group of patients. This work therefore highlights not only the common themes that seem to resonate fairly consistently within Western-based cultures in particular (Mitchell et al., Reference Mitchell, Knight and Pachana2017), but also highlights that wisdom continues to contain an element that is individually driven, likely aligned with the values, beliefs, and philosophical underpinnings of the individual themselves, as well as their own wisdom development pathway (Glück and Bluck, Reference Glück, Bluck, Ferrari and Weststrate2013).
This individually formulated perspective on the end of life and one's attitude toward death may be related to what Monk (Reference Munk2014) calls adaptive resignation, or the gradual recognition that the circumstances of one's life are changing such that time is running out, similar to Carstensen's ideas about changing future time perspectives (Lang and Carstensen, Reference Lang and Carstensen2002). This in turn is related to positive actions at the end of life, such as wanting to pass on knowledge and wisdom to future generations, which may also have therapeutic value in the form of life lessons written and passed on, utilized as part of interventions for those in palliative care (Kasl-Godley and Christie, Reference Kasl-Godley, Christie, Pachana and Laidlaw2014).
Finally, Montross-Thomas et al. offer a conceptual model of wisdom aligned with terminally ill patients that focuses on the balance between two elements: active acceptance and galvanized growth. These two elements are an intrinsic part of the challenge of the end of life experience, as reflected on in the article: “. . . wisdom involved a delicate balance between learning to simply be, while continually striving to change” (p. 6). In this way, the authors capture the lens through which terminally ill patients see wisdom and the role wisdom plays within their lives, knowing that there is an end in sight.
Although in one sense, palliative care has been practiced for centuries, attitudes and approaches to death and dying have shifted, and continue to shift, over time. Thus, current best practice in palliative care remains an area which is deserving of continued research. There are new models emerging which take into account both the need for specialist palliative care practitioners, as well as knowledge of the care for such patients into generalist practice, as well as training the next generation of healthcare professionals to recognize key components of best practice palliative care (Quill and Abernethy, Reference Quill and Abernethy2013). Studies such as that of Montross-Thomas and colleagues brings another perspective on such patients, beyond easing suffering at the end of life, encompassing what that life, and its approaching end, contribute to reflections on a range of human values, including wisdom.
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When we recognize that we don't have all the time in the world, we see our priorities most clearly.
—Laura Carstensen
Montross-Thomas and colleagues begin their article “Reflections on wisdom at the end of life: qualitative study of hospice patients aged 58–97 years” with a quote from Kierkegaard on the paradox of being able to only reflect on life while continuing to live each day (Kierkegaard, Reference Kierkegaard1843). The quote supplied above from Carstensen (Reference Carstensen2011) builds on this idea, suggesting that knowing that one is in the final portion of one's life can sharpen priorities and goals. Carstensen's work on future time perspective (Lang and Carstensen, Reference Lang and Carstensen2002), in the context of her theory of socioemotional selectivity (Carstensen et al., Reference Carstensen, Fung and Charles2003), dovetails well with Montross-Thomas et al.’s findings on the reflections of 21 hospice patients at the end of their life. Although the context of their study was how such patients might find their perceptions of wisdom shaped by the fact of their terminal illness, the patients in this study reported that part of their challenge was to balance accepting their current circumstances, including a foreshortened future, while still striving for growth and meaning.
The participants in the current study responded to a small set of open-ended questions, which were analyzed qualitatively using a grounded theory approach. The two questions of particular relevance with respect to wisdom and the end of life were “What experiences have influenced your level of wisdom?” and “How has your illness affected your level of wisdom?” The majority of patients in the study were Caucasian (81%), male (57%), Christian (48%), and diagnosed with cancer (48%). In terms of age, the range was 58 to 97 years, with a mean age of 78 years. It is important to keep these demographics in mind when interpreting these findings, as both views of wisdom and other theories such as Carstensen's socioemotional selectivity theory have been shown to differ across cultures (e.g. Fung et al., Reference Fung, Stoeber, Yeung and Lang2008). Indeed, Montross-Thomas et al. comment on the variation in conceptualizations of wisdom being dependent on factors including, for example, age, cohort, culture, and philosophical lens. And through their work, they aimed to establish whether a factor such as experiencing a terminal illness might similarly contribute to the conceptualization of wisdom.
The themes that emerge from these patients’ reflections on wisdom align well with available conceptualizations of wisdom, including the work of Bangen et al., which the authors describe in their introduction. This is unsurprising given that in the main, the Bangen et al. meta-review focused primarily on research utilizing participants culturally more like those captured within the Montross-Thomas et al. research. Takahashi and Bordia (Reference Takahashi and Bordia2000) are one of the few who have considered wisdom and culture more specifically, comparing the interpretation of wisdom by those from a Western culture with those from an Eastern culture. Results indicated more of a focus on knowledge and experience in the Western culture, while in the Eastern culture, the focus was more on aging. The examination of cultural influences remains an underdeveloped area within the wisdom literature; studies such as that of Takahashi and Bordia (Reference Takahashi and Bordia2000) highlight the impact that various factors (such as culture) can have on how wisdom is conceptualized.
In addition to capturing the more common themes identified in the wisdom literature to date, Montross-Thomas et al. also capture one of the conundrums of the construct of wisdom, whereby individuals have their own understanding of what wisdom is, and in doing so, interpret their level of wisdom within that conceptualization. In comparison to the Bangen et al. meta-review, Montross-Thomas et al. found that terminally ill patients place similarly high importance on the wisdom themes of prosocial attitudes, behaviors, and decision making. However, the patients also ranked emotional regulation (ranked fifth in the Bangen et al. paper) and openness to new experience (ranked seventh in the Bangen et al. paper) as higher in importance. Reflection and self-understanding and value relativism and tolerance were ranked lowest, while in the Bangen et al. meta-review, the former component was ranked third overall and the latter ranked sixth. Therefore, the link between Carstenson's socioemotional selectivity theory is appropriate, with more consideration given to meaningful social ties, to the sharing of self with others, and a greater appreciation of what is left in life by those experiencing a terminal illness. This is then reflected in what participants see as the most pertinent elements of wisdom, namely those more focused on the meaningful social elements of their lives.
Of course, it is normal research practice to aim to compartmentalize and make qualitative data more meaningful by grouping it into themes. And so, a refreshing element of Montross-Thomas et al.’s work is that they also look to consider the unique insights offered by this group of patients. This work therefore highlights not only the common themes that seem to resonate fairly consistently within Western-based cultures in particular (Mitchell et al., Reference Mitchell, Knight and Pachana2017), but also highlights that wisdom continues to contain an element that is individually driven, likely aligned with the values, beliefs, and philosophical underpinnings of the individual themselves, as well as their own wisdom development pathway (Glück and Bluck, Reference Glück, Bluck, Ferrari and Weststrate2013).
This individually formulated perspective on the end of life and one's attitude toward death may be related to what Monk (Reference Munk2014) calls adaptive resignation, or the gradual recognition that the circumstances of one's life are changing such that time is running out, similar to Carstensen's ideas about changing future time perspectives (Lang and Carstensen, Reference Lang and Carstensen2002). This in turn is related to positive actions at the end of life, such as wanting to pass on knowledge and wisdom to future generations, which may also have therapeutic value in the form of life lessons written and passed on, utilized as part of interventions for those in palliative care (Kasl-Godley and Christie, Reference Kasl-Godley, Christie, Pachana and Laidlaw2014).
Finally, Montross-Thomas et al. offer a conceptual model of wisdom aligned with terminally ill patients that focuses on the balance between two elements: active acceptance and galvanized growth. These two elements are an intrinsic part of the challenge of the end of life experience, as reflected on in the article: “. . . wisdom involved a delicate balance between learning to simply be, while continually striving to change” (p. 6). In this way, the authors capture the lens through which terminally ill patients see wisdom and the role wisdom plays within their lives, knowing that there is an end in sight.
Although in one sense, palliative care has been practiced for centuries, attitudes and approaches to death and dying have shifted, and continue to shift, over time. Thus, current best practice in palliative care remains an area which is deserving of continued research. There are new models emerging which take into account both the need for specialist palliative care practitioners, as well as knowledge of the care for such patients into generalist practice, as well as training the next generation of healthcare professionals to recognize key components of best practice palliative care (Quill and Abernethy, Reference Quill and Abernethy2013). Studies such as that of Montross-Thomas and colleagues brings another perspective on such patients, beyond easing suffering at the end of life, encompassing what that life, and its approaching end, contribute to reflections on a range of human values, including wisdom.