Goodbyes

Going on vacation has become an exercise in trepidation for me. All too often, when I have left town for 2 weeks, a patient close to me has died. The experience of returning to town to learn of a patient’s passing after the fact has turned me to writing as a way of grieving for them, saying goodbye. I began writing what I call “Obituaries” or goodbyes of patients who were often seen in our medical practice, and distributing them to our department members. These obituaries serve many purposes, including: personal remembrance and a living testament to my patients’ lives; as a means to share their lives and deaths with colleagues who may have cared for them over many years; as a way to role model sharing of grief with residents, colleagues, and medical students; as a way to understand things I might do differently in another time or place; and as a way to resolve my own grief over their deaths.

We know that physicians’ schedules are often hectic, with heavy patient loads and little time for recognition or reflection about patients beyond their clinic visits. However, when my patients die, I find that I have often learned lessons from them invaluable to my practice of medicine, and more importantly, to my ability to care for these people as individuals rather than illnesses. Writing obituaries enables me to affirm the value of their lives, of life itself.

Writing patient obituaries enables me to share what I have learned as a valuable teaching tool, as we all learn through common experiences of grief, regret, sorrow, laughter, happiness, and hope. Sharing obituaries affirms that it is good and right to care about our patients and to mourn their passing. This powerful affirmation has a therapeutic way of helping me deal with the loss of patients, many of whom are friends. I have also received positive responses from my colleagues who have received these obituaries (often sent around by E-mail), colleagues who say they are grateful for the opportunity to reflect on their own patients that are still alive.

Over the years, I have been able to accept the deaths of some of my patients more easily than others. Writing about them helps me to deal with their deaths and to critique my own performance in the care of their lives. This honest and sometimes painful reflection often makes me a stronger practitioner.

It is my hope that by sharing obituaries with colleagues and students, I can affirm values of compassion and humility in medicine, values that are needed in practice, frequently forgotten in the life of a busy practitioner, and very difficult to teach. Perhaps others will also be inspired to write recollections of their patients for themselves, their students, and their colleagues.

• PT died late last summer. He had been a tough survivor, living for 23 years with an aortic valve replacement, 23 years on blood thinners to keep his blood thin enough to prevent a stroke from the artificial valve but not too thin to cause bleeding episodes. He lived through heart failure, neuropathy, diabetes, atrial fibrillation, colon polyp surgery and its complications, and finally a stroke caused by too much coumadin.

PT and I knew each other for 8 years, but only through the narrow window of chronic illness and death. As I reflect, I remember a man greater than the sum of his illnesses. He eventually lost 40 pounds over a 2-year period when he realized that it was one of the few interventions that he could do that would significantly and positively improve his quality of life. He was married for over 45 years, and he raised his niece as his own because he and his wife never had any other children. PT, in death, reminds me of the dignity with which many patients with chronic disease live despite their illness; he reminds me of the imperceptible, but incredibly important, lessons they share with us about life and dying, if we are willing and able to listen.

• SM is a patient who died recently of metastatic pancreatic cancer. After 3 decades of service as a secretary, her plans were for travel and adventure, for experiencing new tastes, sounds, and sights. Those experiences ended up only as dreams, cut short by surgery, chemotherapy, and radiation only 6 months after retirement. Her infectious smile and keenly insightful questions belied a simplicity of appearance and manner and probably surprised many of her clinicians. She managed her brittle diabetes with grace and great acumen. SM lived with her sisters, and although she had no children or spouse, her sisters were lifelong companions. It was fitting, although sad, that the first time I met her sisters was when the terminal diagnosis was given. SM was grateful and strong, and she rarely complained of pain, even after an attempt at disease cure with major abdominal surgery. She was optimistic, so who was I to presume differently? I learned of her death the way most physicians learn of their patients’ passing: I called her sister to say I had not heard anything in 6 weeks, only to hear that she had died suddenly 4 weeks before.

• RM died one December, several weeks after successfully recuperating from prostate cancer surgery, or so it seemed. A long time worker at Red Cross and HIV positive, I just couldn’t believe that he had a sudden massive heart attack. Deaths that are more progressive than sudden, or processes that last longer and can be anticipated, seem better. RM placed complete trust in our clinic staff, doctors, and nurses. While needing specialty care, he placed his premium solidly in the model of family medicine and its emphasis on continuity of care. At his funeral, it was wonderful to see RM’s older brother who looked just like him. It was also wonderful to see many other HIV patients from our practice who were there celebrating his life—the family in family medicine.

Patient deaths occur in quiet suffering, with outer strength, through fear or isolation, with family or friends, suddenly or over long periods of time. Writing obituaries allows me to say a goodbye of sorts, gives me some resolution. I also begin to think more about the attributes of a physician that I would like to aspire to. One of the things that we, as physicians, may forget in the business of healing is that ultimately, all our patients will die. Thus, the process of caring, the journey for celebrating our patients’ lives, is what is important, even more than the eventual outcome. After all, we too shall pass one day. When that time comes, perhaps someone will write something about our life and death that will make them a better person or a better clinician.

• Received for publication April 2, 2005.
• Revision received February 7, 2006.
• Accepted for publication February 9, 2006.