An email was waiting for me one morning from my wonderful nurse, Laura. "Very sad day," it said in the subject line. I opened the email quickly upon receiving it (we had just recovered from a northeast blizzard, after all) and read that one of my patients had died. This age-old dilemma again made me wonder what I should do: Should I call the family? Send an email or a card of sympathy? I also wondered whether I should attend her wake, her funeral.

As physicians, we forge a very special relationship with our patients, the proverbial doctor-patient relationship. For those of us in oncology it is almost primal; we meet under the threat of a life-ending illness, prescribe treatments, bear witness to the intended effects and the unintended side effects they experience, and (hopefully) watch as our patients emerge on the other side of treatment to become survivors. And we hope that each one will be cured and see years despite cancer.

I have never underestimated this relationship, the importance of bearing witness. Early on in my career, each death from cancer broke my heart; I went to every funeral, spoke with each family, cried over every loss. And it nearly forced me out of oncology; out of medicine. How could I possibly endure losses so personally, knowing that they are an almost routine part of oncology care? Clearly, I needed to find a way to persevere. 

It was then that I realized that what I "needed" most was an ending; that for me, on an emotional level, the sorrow and the tears did not compensate for the missed opportunity I had to say goodbye. I realized it was as important for me to find closure as it was for my patients. So I made a decision—a conscious decision—not to attend wakes or funerals. Instead, I made it a point to say goodbye; whether it was to the patient I was referring to home hospice or the one I was telling it was "time"; when a patient of mine reached the terminal point of her cancer, I promised myself I would seize the opportunity to say goodbye.

Though years have passed, I still recall the last visit of a patient I had treated for an extended period of time. She had come in in a wheelchair, had temporal wasting, and appeared profoundly exhausted. It was clear she was dying, and we both acknowledged that. I suggested hospice and she agreed, as did her family. She and her family cried; I promised her I would be her doctor, no matter what.

Prescriptions were given and plans were made, but before I left the room, I looked at her and said the words that have become my guide for future such encounters:

"It was the greatest honor of my life to be here for you and to get to know you and your family...thank you for the letting me be your doctor; I don’t know if we will see each other again, but let me tell you now because I can, and because you are here—goodbye; I will always be here for whatever comes to you and your family—but I just needed to say this to you now."

When I remember these words, the fleeting questions that come to me regarding how to personally respond to the loss of a patient fade away.

There is no one "prescription" on how to end the doctor-patient relationship when a patient reaches the end of life, and as clinicians, each of us must find the method that brings us peace of mind when that relationship ends. For some, it means sending the card and/or calling the family, while for others, it is important to attend that wake or that funeral. For me, it comes by looking my patient in her eyes while she is still here, acknowledging she is nearing the end of her life, and holding her hand. Realizing that the path we walked together is about to end; it also means taking that opportunity to say goodbye.

If anything reminds me of the honor of being a physician, it is this moment. As sad as it always is, saying goodbye is an important lesson we must all learn, and it will serve us well if we do it "right."


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