At Clermont-Ferrand University Hospital, end-of-life care is filled with tasty indulgences. And brain research is confirming why that makes for a good ending.
By Jessica Wapner | Published Mar 2, 2022 8:25 AM
This story originally appeared in the Taste issue of Popular Science. Current subscribers can access the whole digital edition here, or click here for a new subscription.
Christmas festivities meant little to the 50-year-old man with a neurodegenerative disease that left him unable to chew or swallow. Food, delivered by tube straight to his stomach, gave him no solace. But the lights were twinkling and the music playing and Virginie Guastella could not stand to see this man so far removed from the fun. So she diluted a little red wine and dropped it on his tongue. Not enough for him to swallow, just enough to saturate his taste buds and light the pleasure centers of his brain. She knew this Christmas would probably be his last, and she wanted him to have something he loved at least one more time. He smiled, looked up at Guastella, and said, “Again?” She indulged him. How could she not?
Guastella was neither family nor friend. She was his doctor, namely the chief of the palliative care unit at Clermont-Ferrand University Hospital (CHU), a public medical center in south-central France. Ringed by the storied wine regions of Bordeaux, Sancerre, and the Loire Valley, Clermont-Ferrand is home to six universities, a chain of volcanic mountains, a black cathedral made from lava, and what is likely the world’s only hospital-based wine bar, the sole purpose of which is to bring contentment to patients in pain or at the end of their lives. Guastella started the service several years ago, and it has been a hit ever since, beloved by patients, staff, and the many vintners who have donated case after case. It is living proof of the transformative power of sensory pleasure.
Recent findings in neuroscience indicate that she’s onto something. For years, the hedonistic pathways of the brain—our reward center—have been more closely associated with guilt or abuse. But an increasing body of evidence shows that our sense of fulfillment, and even our will to live, is closely tied to the activation of this pleasure region. Wine in particular can light up our gray matter in ways that fulfill us on multiple levels by steeping our senses in delicious flavors and aromas, connecting us to others, and facilitating moments that give us strength and comfort.
Yet delectable food—let alone alcohol—at the bedside of a dying patient is usually given short shrift by the powers that be. Commodities that are cheap, scale up easily, and require little to no chewing typically fill dining trays. Providing the pure contentment of a satisfying meal is not the job of healthcare systems.
Guastella takes the opposite approach, prioritizing humanity over economy. Now years of intricate studies are leading researchers in neuroscience, psychology, and palliative care to a straightforward truth about the end of life, one that perhaps was obvious all along: Simple pleasures can make for a happier ending.
In the summertime, four types of mint grow in an herb garden on the balcony off a kitchen in the palliative care unit at CHU. Cherry tomatoes too. Across the hall, Guastella’s tidy office smells like orange blossoms, and a floor-to-ceiling window looks out on a quiet courtyard. Against her white lab coat, dangly earrings and wedge-heeled sandals appear like subtle statements declaring her wish to breathe life into medical care.
Guastella joined CHU as a palliative care physician in 2003 and learned how much more there was to give patients beyond pain medication: care, time, conversation, little treats. She cites the French expression les carottes sont cuites (“the carrots are cooked”). It means nothing more can be done. For Guastella, the carrots are never cooked. “In palliative care, there is always something to offer,” she says.
Sometimes that offering came in the form of alcohol. A nurse might sneak a bit of whiskey to someone. The palliative care unit gave patients wine or champagne on special holidays. But Guastella was dismayed by what passed for wine—and it came in plastic bottles. Even today, her green eyes widen as she recalls her reaction: “Stupefaction!” she says, throwing her hands in the air. She refused to give it to her patients. “It is not possible,” she said, with case-closed finality. Plastic was undignified. Ugly. It undermined the pleasure the drink was supposed to bestow. “Why, because you are hospitalized, do the good things have to be stopped?” she says.
Then, in 2013, a colleague introduced her to Catherine Le Grand-Sébille, then an anthropologist at Lille University School of Medicine studying our connection with wine—including at the end of life. In the prior couple of years, Le Grand-Sébille had conducted 200 interviews with doctors and other medical staff, nonmedical caregivers, families, and patients about preserving sensory pleasure. Clinicians spoke about the importance of stopping medication that dulls the palate when the drug outlasts its usefulness. Patients spoke about wanting the wines they had enjoyed all their lives. A student nurse felt it was an abuse of power to forbid a nonagenarian who has led a full, independent life from drinking a glass simply because it’s “not done” in a hospital setting.
By this time, Guastella had become chief of the palliative care unit at CHU. She approached the director of her division with the idea of starting a wine bar for terminal patients. The response was an immediate yes. It wasn’t a bar with stools and a bartender that Guastella was requesting, but rather a storehouse of good bottles that she would feel proud to serve. She purchased an armoire a vin, a temperature-controlled wine cabinet, for about 800 euros with money donated to support hospital programs and volunteers. A burst of news coverage followed. Several vintners donated cases, and patients have been offered wine from real bottles poured into real glasses ever since. The cabinet is always full, and there’s a closet stacked with dozens more bottles. There’s champagne for special celebrations and even hard liquor for the occasional summertime punch. “I don’t want to make patients drink a lot,” says Guastella. She just wants to help them maintain a sense of normalcy and dignity.
They do. Take François, a patient who was dying from kidney cancer at age 73. Soon after arriving at CHU, his sense of taste began returning and he told his wife he wished he could have some wine. “He said he wanted a nice red,” she says. One day, his lunch arrived with exactly that. His eyes lit up as he drank it. “At that moment, my husband wasn’t a patient anymore,” she says. “He found his humanity, his dignity, again.” The CHU palliative care unit has a journal filled with stories like this.
Guastella had been following her instinct when she first arrived at CHU in 2003. But by that time, researchers had already made key discoveries about the systems that regulate what neuroscientists refer to as our wants and our likes. Wants encompass our survival needs—eating, drinking, sleeping. Likes encompass the specific ways in which we satisfy those needs—favorite foods, drinks, even a certain pillow. In other words, what neuroscientists call “wants” are really our needs, and what they refer to as “likes” are what make us happy.
Of course, these pleasures aren’t our only source of contentment. Scientists and philosophers identify two types of happiness: eudaemonic and hedonic. The former has to do with making life meaningful—our values, the principles we uphold. The latter makes it bearable: wine, chocolate, perfume. These are the likes that satisfy our wants. And they also turn out to be more complex than merely craving tasty treats.
Prior to the late 1980s, neuroscientists believed that dopamine, the neurotransmitter linked to rewards, was triggered by things we like—that we seek out sweets because of the hit we get from consuming them. But a series of studies by Kent Berridge, a psychologist and neuroscientist at the University of Michigan, and colleagues showed that when they reduced the amount of dopamine in rats, the animals liked sweetness just as much as when the transmitter was active (rats have a particular tongue rhythm and facial expression when they scarf yummy foods), which suggested that they weren’t seeking sweetness only for the rush. And in 1989, Berridge and Terry Robinson, another UM neuroscientist, found that when the chemical was blocked entirely in rats, they stopped eating and drinking voluntarily yet still liked sweetness. “They had to be kept alive, like in a hospital, with artificial feedings,” Berridge says. But once food was given to them, they ate as usual. They liked the food, they just didn’t seek it out. Taking away dopamine obliterated their will to live.
The surprising finding led Berridge and Susana Peciña, a graduate student at the time, to probe further. In 2003, they published a study in the Journal of Neuroscience showing that rodents with extra dopamine preferred sweet rewards, but how much they liked them—again, gauging by their facial expressions and eating style—remained the same. A few years later, they made a truly remarkable discovery when they injected opioids into a tiny region of the brain called the nucleus accumbens. Whenever they and other researchers had tried this with other regions of the brain, the “wanting” reflex was stimulated. But this time, the rats showed a heightened level of pleasure from their food. They liked it more. Subsequently the duo found more hedonic hotspots—as Berridge and Peciña, now a psychology professor at UM, called them—that together form a circuitry that appears to intensify pleasure. Wine, for example, activates the hedonic circuitry, and that activation heightens the bliss.
In the years since, Berridge and others have continued to identify the regions that govern these highs. According to a paper published early in 2021 in Behavioural Brain Research, for example, the central nucleus of the amygdala stimulates wanting but not liking. And the circuitries for liking and wanting not only occupy different areas but also function differently. Liking is easy to disrupt, says Berridge. We move on to another favorite meal. We favor a crisp white wine in the summer and a full-bodied red in the winter. Wanting is far less flexible, he explains, probably because it helps keep us alive. We have to want to eat, we have to want to procreate. Otherwise we die and go extinct. The fact that we like food or sex is a bonus.
Which raises the question: Why have likes at all? Why do we get so much satisfaction from a juicy peach or a glass of pinot noir, when all we really need is to want to eat and drink in order to stay alive? Neuroscience doesn’t have an answer to that yet, but it does have a prevailing theory. “Maybe it’s because it serves to broaden the targets of our wants,” Berridge offers. After humans discovered alcohol, they started wondering how to ferment things on purpose—to control the process and make it more sumptuous. We don’t need booze to survive, but realizing we like it expands our options for satisfying our thirst.
Just as the basic survival need to want food leads to liking it, so can enjoyment cause survival instincts to kick in. A 2001 study by Berridge and Cindy Wyvell, a postdoc in his lab, showed that wanting could be triggered by sensory cues. “Most things that turn on liking will also turn on wanting,” says Berridge. This phenomenon is why the smell of freshly baked bread can make us suddenly ravenous—a random like activates a primal need. This process is also apparent in what happens when pleasure is taken away. Anhedonia, or the inability to experience pleasure, is a common symptom of depression. It can lead to suicidal thoughts. It’s a state of mind that Guastella has seen often. “If we can’t bring the pleasures of life to patients, that’s when we start seeing them wondering about euthanasia,” she says. But the connection between liking and wanting means that a small delight like wine can help dissipate anhedonia, a stroke of evolutionary genius that her team has witnessed time and again. The phenomenon has inspired Guastella and her team to add more sensory thrills over the years, like tastings of caviar and French pastries.
Severine, a patient diagnosed with lymphoma at age 30, came to Guastella’s unit when her doctors believed there was nothing more they could do. There she helped make crêpes with the other patients and ate meals off real dishes. Her boyfriend, Benoit, would enjoy a glass of wine at her bedside. “You don’t feel like you’re in a hospital,” she says, and she has outlived her prognosis by several years. No one can say whether her likings activated her wanting—whether small moments of enjoyment restored her will to live—but to those around her it sure seems that way. “It’s a miracle she’s still alive,” says Benoit.
Domaine Haut Moulin d’Éole stretches across 100 acres in Beauvoisin, a small village of about 5,000 people in southern France. The four Rouvin brothers inherited the vineyard from their father, who had survived a stroke in 2002 that left him partly paralyzed but still able to enjoy his daily glass of vin. By 2015, though, advancing Alzheimer’s disrupted his ability to swallow, and his doctor advised him to stop imbibing. “If I don’t drink wine, why am I here?” he asked his sons. He died a week later. So when one of the brothers, Fréderic, heard about Guastella’s wine bar on the radio, he was immediately moved to donate. “We think it’s normal to help people at the end of their life,” he said over lunch, ice cubes clinking in a glass of rosé. The brothers don’t believe that wine was specifically keeping their father alive, but it’s easy to see how taking it away could also have diminished his sense of purpose. “Wine is life,” noted Annie, a patient at CHU’s palliative care unit. “Everybody knows that.”
Earlier this year, physicians at the University of Malaya in Kuala Lumpur, Malaysia, sought to elucidate what exactly makes a good end to life. They asked 15 palliative care patients about happiness. “It can take many forms,” one responded. “It can be a pain-free day, a visit from friends, and a nice meal.” Another included being able to eat what they enjoyed. But the group also found that as a terminal illness progresses, people become more focused on something else: meaning—a eudaemonic pleasure. And like the hedonic variety, it has its own circuitry and triggers.
For many people, wine provides both types of happiness. The taste matters, says UM’s Berridge, but there’s more to it. “It’s the recapturing of normal life again, as opposed to just being in a sterile hospital environment.” Morton Kringelbach, a neuroscientist who runs the Centre for Eudaimonia and Human Flourishing at Oxford University, sees the communal aspect of wine drinking as core to its benefit. “The most important pleasure is that of other people,” he says. “Wine can become meaningful because you share it.” In another survey by the Malaysian researchers, relatives of patients in palliative care said that their contentment depended largely on their loved ones’ happiness in their final days. Relatives of CHU patients similarly speak about the sense of normalcy and intimacy they felt just from sitting by the hospital bedside, chatting over a glass of wine together.
The brothers don’t believe that wine was specifically keeping their father alive, but it’s easy to see how taking it away could have diminished his sense of purpose.
For someone in a hospital bed, the enjoyment of wine isn’t just about the taste; it’s about the meaningful thoughts and feelings it evokes. Research indeed does point to a biological connection between hedonia and eudaemonia. Studies from the University of Illinois and KU Leuven, a Belgian university, have found that people who report hedonic happiness also feel the eudaemonic variety. And neurological investigations at the University of Oxford, McGill University, and elsewhere have revealed that areas of the brain that respond to carnal pleasures like sex overlap with those that respond to music. Kringelbach and others have identified regions of the orbitofrontal cortex lit up by both hedonic and eudaemonic pleasures.
Still, it’s difficult to envision US hospitals adding wine bars. “Introducing any sort of alcohol would be fraught with attorneys telling us we probably shouldn’t do it because somebody might fall,” says Jayson Neagle, assistant professor of palliative medicine at Northwestern Feinberg School of Medicine. He occasionally suggests a brown-bagged libation on the down low, advising families to ask forgiveness instead of permission. But more often, he relies on other vehicles for providing comfort, such as aromatherapy for patients who have lost the ability to enjoy food.
Still, Guastella’s approach to dying may just have some wisdom for the living. “So much of our lives is spent pretending that we shouldn’t really allow ourselves to enjoy pleasure,” says Kringelbach. Hedonic happiness has become stigmatized by hedonism—pleasure for pleasure’s sake— and its association with addictive behaviors. But deprivation has consequences, he says. It tends to increase our desire for the thing we are trying to eliminate. “Having a little bit of chocolate is better than not having any at all.” Kringelbach also returns to the connection between hedonia and eudaemonia: Sharing the joys of life with others is a meaningful way to be together. “Pleasure can have a transformative effect,” he says, “if you will let yourself be open to it.”In 2018, Guastella reported in Nursing and Palliative Care the results of a small preliminary survey her team conducted to gauge the benefit of the wine bar. Among 44 patients, 36 said they appreciated the service, and 30 of 32 relatives concurred. “It is a good way to pass away feeling happy,” one patient responded. “Opening a wine bar at a palliative care unit is just a way to give the patients the opportunity of feeling alive,” the authors wrote. Or, as winemaker Antoon Jeantet-Laurent put it when he came to CHU to drop off 15 cases, “Even if it’s the end of life, you’re still alive, so why not continue living?”
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At Clermont-Ferrand University Hospital, end-of-life care is filled with tasty indulgences. And brain research is confirming why that makes for a good ending.