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Final Good-byes

HARPHAM, WENDY S. MD

doi: 10.1097/01.COT.0000340709.18234.82
View from the Other Side of the Stethoscope
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Dr. Solor lifts the cold, full coffee pot at the deserted nurses' station, thinking, “This is odd.” Just then a muffled swell of laughter rises from the conference room at the end of the hall, and he remembers.

A familiar husky voice from behind startles him. “The quiet feels eerie, eh?”

With a bright smile, Dr. Solor turns to her and offers his filled cup, “Coffee, Dr. Katz? It's cold; you'll have to nuke it.”

“No thanks. I'm headed over to Theresa's retirement luncheon. Want to join me?”

“You go ahead. Dictations are calling,” he says, tipping his head toward a computer screen.

“Aw, c'mon. The dictations can wait; today is Theresa's last day.”

“Maybe in a bit…”

“All right,” she says, but she doesn't make a move.

“I'll miss Theresa,” he offers, as if asked to explain. “Truth be told, I just never know quite what to say at those things.”

Dr. Katz nods and repeats, “All right.”

Dr. Solor could tell from the tone of her voice and the look on her face that she is thinking about more than Theresa's retirement.

“Speaking of good-byes,” Dr. Katz says tentatively, “I spoke with our patient, Jeff, yesterday.”

“You did? Is there a problem with hospice?”

“No, no. He's very happy with hospice.”

“Good,” Dr. Solor is pleased. “That's good to hear.”

“In fact,” Dr. Katz says, “Jeff mentioned how grateful he is to have them.”

“Then why did Jeff call you?”

“He didn't. I called him.”

Dr. Solor leans against the chair by the computer, feeling uneasy and unsure why.

Dr. Katz continues, “Medically, things are going smoothly.” Dr. Katz clears her throat. “You need to know: Jeff is pretty upset with you.”

Dr. Solor's stomach drops. He has no clue what she's talking about.

“It seems you never said good-bye.”

Dr. Solor blanches and his mouth drops open, “What!?”

“I was shocked, too,” says Dr. Katz. “You guys had such a great relationship.”

“Good-bye?” Dr. Solor looks confused.

Nodding, Dr. Katz says, “Apparently at his last office visit, he asked about his next appointment, and you said something to the effect of ‘You don't need another appointment. Hospice will take care of everything from now on.’”

“Okay.” Dr. Solor is visibly distressed. “And?”

His mind scrambles to understand. “I remember exactly where I was standing when I explained that hospice has the specialized skills needed for him to get the best possible care.”

Dr. Solor shakes his head. “I guess I'm missing something.”

“All I know is Jeff feels abandoned,” Dr. Katz responds. “He talked about how all these years he thought you cared. How you helped him through difficult decisions, treatments, and crises.”

A lop-sided smile crosses Dr. Solor's lips. On the bulletin board in his office, somewhere among the collage of pictures sent by other patients, is an image of Jeff. He's proudly holding up his “this big” fish, the feisty trout Jeff caught shortly after his prolonged hospitalization—half of which he spent intubated in ICU with DNR orders on the chart.

Dr. Katz concludes, “It's just not a good situation. Jeff feels hurt. Now he thinks he was mistaken all these years—that you must not really care.”

“How could he possibly think I don't care?” Dr. Solor is stunned. “I do care.”

“Of course, and I told Jeff how much you care about him.”

“Did you explain why I didn't say good-bye?”

Dr. Katz leans toward Dr. Solor. “I just repeated what I knew: I assured Jeff that you do care about him.”

Dr. Solor drops his gaze to the floor, mumbling, “I thought what I did was right, but I guess…” He retreats into his own world, straining to recall every nuance of every word exchanged at Jeff's final visit.

Dr. Katz reaches gently for his elbow, “C'mon, Doc. Let's go to that luncheon.”

This story is not purely hypothetical. A friend of mine had glowing esteem and gratitude for his oncologist's care throughout his years and rounds of treatment. This friend was devastated by his final visit with his oncologist.

I immediately reminded my friend that many people—not just physicians—have trouble saying “good-bye.” But I couldn't account for the abrupt ending that left him feeling abandoned. My efforts to comfort my friend felt hollow.

Under any circumstances, saying good-bye is emotional if the relationship is meaningful, especially if the parting may be forever. Yet I cannot think of a single non-medical situation where departures are not marked with words or rituals of closure.

For physicians, final good-byes can be uncomfortable. They dramatize the limits of physicians' abilities to cure. Some physicians equate saying “good-bye” with admitting defeat. Others, fearing that their patients might interpret these potent words as two nails in the coffin, deliberately avoid “good-bye” so as not to risk extinguishing patients' hope.

To leave room for patients' hope, physicians can say something like, “I'll be keeping my eyes open for you. If a new treatment becomes available (or if your condition unexpectedly improves), you can leave hospice and I'll resume your care.”

As for softening the good-bye, you can let them know, “I'll be checking in on you through the hospice nurses.” Better yet, tell them you will call them in a week or two, socially and just to say “Hi.” If your schedule doesn't easily allow post-discharge communications, maybe you can find some way to say, “With hospice taking care of your needs now, I won't be caring for you anymore. But I'll still be caring about you.”

The transition to hospice is emotionally complex. Whether a patient is adjusting well or not, physician-patient communications can too easily become confused. A final good-bye can be healing for patients. And for physicians, too. Because the pain of “good-bye” acknowledges all that is good.

© 2008 Lippincott Williams & Wilkins, Inc.
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