Six questions to reduce end-of-life regrets in health care

A growing body of health-care guidance emphasizes patient-centered conversations about what matters most as illness advances. A death doula’s framework, known as The Final Checklist, invites people to address six core questions that often surface too late. The approach gained renewed attention after a patient named Nathan, diagnosed with amyotrophic lateral sclerosis, began a long struggle from tremor to paralysis. Over four years he moved from walking to relying on a single-knuckle tap to communicate, eventually wrestling with the knowledge that time was shrinking. He wrote a four-page letter to his end-of-life doula, describing a longing for acceptance, a desire to mend old wounds, and gratitude that found its way through the slow process of typing letters one keystroke at a time. Nathan did not live to see all the conversations he hoped for, but his experience illustrates a central insight that Diane Button, a death doula for two decades, has offered to countless clients: you cannot wait until you are dying to discover what matters most.

Button has spent years guiding people through the emotional, spiritual, and practical realities of dying. Her work centers on what she calls The Final Checklist — six deceptively simple questions designed to surface regrets, mend relationships, and bring peace in a person’s final days. The questions are not meant only for those facing imminent death; they are framed as a tool for living more fully now, while there is still time to act. Button says the practice has deepened her own relationships, clarified priorities, and helped many clients move beyond regret.

The six questions, taken together, form a practical roadmap for reframing daily life around what truly matters. First, Who matters most? Many people spend years forming a wide circle of acquaintances and casual friendships, yet in the final days it is a small group of people whose hands one would want to hold at the end. A common reflection, Button notes, is that the most meaningful connections are often the ones that require action in the present. In one case, a client waited two days for a brother to arrive, only to die just after their eyes met. That story underscores the urgency of reaching out before time runs out and reinforces the point that these relationships deserve attention now, not later.

Second is What matters most? As possessions and titles fade, deeper elements such as spirituality, connection, and contribution rise in importance. The emphasis shifts from accumulating to sharing; the question invites people to direct energy toward actions that align with core values rather than with external achievements.

Third, What keeps you awake at night? Understanding a person’s pulse of worry helps the care team address what disturbs sleep and quiet the mind. One client who had left a religious upbringing sought a sense of “something more” and found that peace hinged on the possibility of closing the gap with her faith community. Her story demonstrates how unresolved fears, even about the afterlife, can impede a peaceful passing unless acknowledged and addressed with honest conversation.

Fourth, What brings you joy in the daytime? Despite confronting mortality, many clients become the most present and joyful people Button encounters. The simple pleasures—the warmth of sunlight, a comforting routine, time with loved ones—grow into the core of daily happiness. Some describe choosing to focus on intimate moments with children or pets, rather than on external demands or anxious preoccupations. Naming and protecting these joys can infuse days with purpose even as life narrows.

Fifth, What is left unsaid? Unspoken words can weigh heavily in the final chapters. Saying I’m sorry, thank you, or I forgive you can bring relief to both sides of a relationship. In one family, a parent who never said I love you found that these phrases, spoken or written late in life, carried a healing power that could not have been achieved by grand statements or distant gestures. The question invites people to repair or complete emotional lines of communication before the moment passes.

Sixth, What is left undone? Regrets can center on unfinished dreams, but the emphasis is not on grand achievements alone. Even small, concrete steps toward a passion—art classes, poetry readings, or inviting someone to move in—can provide relief, purpose, and peace. Button notes that clients who pursue even modest, meaningful acts toward their deepest interests often leave life with fewer regrets.

In practice, the six questions work as a continuous check-in rather than a one-time exercise. Button herself revisits the prompts monthly, a habit she extends to her own life to avoid postponing what matters most. The aim is not to fear death but to harness one’s remaining time to strengthen relationships, savor present moments, and move toward meaningful outcomes that align with personal values. The approach resonates with clinicians and palliative-care teams who emphasize that conversations about goals, fears, and legacies can improve quality of life and patient satisfaction, even when medical options are limited.

Nathan’s letters near the end of his life are often described not as grand declarations but as expressions of gratitude and reconnection. His deepest wish was to convey thanks to friends who had shaped his life, a reminder that clarity in communication can become a lasting gift for those left behind. The Final Checklist, as described by Button, is a framework for both reflection and action: ask the six questions, write down the answers, and revisit them as circumstances change. The aim is to guide how people spend their time, the words they utter, and the people they choose to hold close.

The health implications of these conversations extend beyond individual choice. With aging populations and increasing numbers living with chronic illnesses, professionals are increasingly recognizing the value of early, ongoing discussions about values, fears, and priorities. The Final Checklist does not replace medical decision-making; it complements it by ensuring that medical interventions align with what patients truly want and need. In this sense, the approach supports patient-centered care by clarifying goals and facilitating better alignment among patients, families, and care teams.

Ultimately, the core message is pragmatic and compassionate: you do not need to wait for the final days to begin living with intention. The six questions offer a structured, humane way to address unresolved issues, strengthen connections, and find peace in the face of illness. They encourage people to identify what matters most, to take steps toward those priorities now, and to accept that some aspects of life may not be fully within reach while others still are. In Button’s words, answering honestly reveals a clearer path to living with fewer regrets and a greater sense of meaning, even when the clock is ticking.

Diane Button is a death doula and author of What Matters Most: Lessons the Dying Teach Us About Living, published September 16 by Open Field. The six-question framework stands as a practical tool for patients, families, and health-care providers seeking to navigate the difficult, often emotionally charged terrain of end-of-life care with honesty, empathy, and a focus on what truly matters.