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How to say a last goodbye?

By: Prof. B. Koren

"I came to say goodbye", I told him, "I Knew you would" he said. Everyone wants to bid their loved ones goodbye. How can you do it properly?

It’s never easy to confront the finiteness of life. This difficulty is one experienced both by terminal patients as well as their families and loved ones.

After receiving the news, the patient himself is left with a limited amount of time to internalize his situation, reflect on his life and attempt to reach some form of closure. Family and loved ones on the other hand undergo a similar emotional process but are simultaneously required to accommodate the patient’s physical and emotional needs. Within this framework, important issues are often avoided and genuine acceptance is rarely achieved.

Randy Pausch attempts to address this issue from the patient’s perspective in his lecture suitably entitled "The Last Lecture". 
Pausch was a professor of Computer Sciences at Carnegie Mellon University in Pittsburgh who was diagnosed with terminal pancreatic cancer, leaving him a mere 3 months to live. In his lecture, Pausch instructs his listeners on how to achieve their childhood dreams. During the preparation of his lecture, Pausch essentially created a checklist of all the things he held dear. This process of acknowledgment enabled him to peacefully part with the people he loved. 

Separation and Regret

Parting is hard. It entails confronting our basic instinct to deny our own finality which in itself calls on substantial emotional maturity. At the same time, it embodies a final opportunity for emotional growth and development as individuals.
Within the context of oncological patients, who I am dedicated to treating on a daily basis, this is a multifaceted process which takes place independently on numerous levels. Throughout the course of a patient’s life, intricate relationships are formed with his family, friends and even the medical team charged with his care.

These relationships are varying in nature and are characterized by different levels of intimacy. Often times a patient is able to reach closure with his partner but is unable to overcome other emotional barriers which hinder his ability to gain intimacy with the medical team attempting to treat him. In other cases, a patient may be unable to reach internal peace with himself. Who should initiate this process? Who is best suited to guide and support the patient through this emotional journey? Neither of these questions have clear answers. 
A few weeks ago, the partner of a patient of mine reached out to me. The patient was a middle aged man who had recently passed away from lung cancer. The two had lived together for some time following conclusion of their unsuccessful marriages. The chemo and radiotherapy weren’t effective and the battle was lost sooner than expected.

Throughout his sickness she was determined and dedicated to maintaining the "perfect" relationship. This fixation barred them from delving deeper into difficult emotional topics and following his passing she felt a harsh lack of closure. She turned to me in distress, desperately seeking a way to tie up the remaining emotional loose ends between her and the man she loved. Unfortunately this realization was late in coming, attempts at reconciling the situation were unhelpful and she was clearly filled with regret. 

Words to a Dying Friend

I am far from an expert on farewells, despite the fact that they are quite common in my line of work. Their frequency however does not diminish the feeling of ambivalence I encounter whenever it’s time to part with a patient. Not long ago I treated a patient who was suffering from a very aggressive tumor which had spread to his prostate, bones and brain. Rapid dissemination of brain metastasis led to drastic deterioration of his physical function. Very soon there was nothing more I could do to help him.

I was his treating physician for four years, during which he received all the standard treatments as well as a battery of experimental drugs that I had at my disposal. I knew that I was obligated to give him the final news but at the same time, the idea of confronting him terrified me. Did I have the courage to inform the patient, a highly intelligent engineer perfectly capable of connecting the dots, that he was about to die?
This situation required more than a simple gesture, it needed to be done carefully so as not to rob him of any remnants of hope. I walked over to his room, and slowly sat beside his bed. I massaged his neck to relieve the pain caused by his spinal cord tumors. When I stopped, we both sat in silence for nearly ten minutes which to me felt like an eternity. At long last we looked at each other; "I came to say goodbye", the words slipped out of my mouth."I knew you would come’ he replied.

Ironically, a joyous expression spread across his face; "I am very grateful that we both have the courage to be here for each other. Neither of us would have been able to bear the emotional burden of not sharing this moment".
Everyone wants to bid their loved ones goodbye. Towards the end of his book, Randy Pausch quotes an Indian thinker named Krishnamurti. When asked what the appropriate words to a dying friend would be he replied: "Tell him that with his death, a part of you will die and go with him. Wherever he goes, you will be with him so that he will not be alone". 
Professor B. Koren is a Director of a Radiology department 

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