It probably started with my father’s death 30 years ago. It was sudden and shocking, but life rushed back in to fill the emptiness. All was well for years, until my mother died, followed by my mother-in-law within a year. We immersed ourselves in sorting out the detritus of decades of two women who had lived alone. A fancy but cracked China plate repaired with a Band-Aid, but kept, just in case. Objects of great, if idiosyncratic, personal worth. We didn’t reflect on it much at the time, we just put our heads down and tidied, sorted, distributed, trashed, sold and donated.
Recently, a senior doctor I know developed metastatic cancer and died. He saw his last patient 48 hours before the end. Another physician became sufficiently infirm that he “had” to retire at 90 years of age. Patients he had been seeing for decades now depended on his colleagues to find them treatment. These were two wise practitioners who understood about living and dying, about mortality and endings, but seemed to act as if they didn’t see it coming, as if they would always be there for the next appointment. A never-ending series that went on to infinity, I guess. Despite my own good health, I always thought I was well aware of death, given that I work in a cancer centre. But the awareness that started 30 years ago with my father’s collapse became more acute now. Death can be sudden and unexpected, but it is inevitable. It was important to start thinking about my own end.
So, I have started in again on the sorting tasks, except this time, it’s my stuff. I don’t want my family to have to decide what to do with Dad’s collection of broken tools or the Green Bay Packer action figures when I’m gone. My colleagues can clean out my space if I don’t get the chance, but I’ll save them the trouble of riffling through the files of interesting papers that I will read soon, when I have the chance, many of which are more than 10 years old. At home, I’ve made a crucial shift from finding more space for the stuff to reducing the stuff to fit in the space. So far, so good. It isn’t sad. It gives me a nice sense of accomplishment. I can plug away at it, I can take breaks. Over time, I plan to leave less for those who come after me.
But I also have patients, who are much more important than clutter and not straightforward like papers and objects. Like most psychiatrists of my generation, I was trained in psychodynamic psychotherapy, which was, at least during my residency, pretty fuzzy on the whole ending thing. We had exactly one seminar, 45 minutes in total, on how to “terminate” with a patient. So, even though my day job is seeing people with serious illness and helping them with that adaptation, a task that may take from one appointment to two or three years, I have another group of folks I have treated for many more years.
How long is many more years? Like 25. Or 20. Or sometimes “only” 15. We call these patients “lifers,” which sounds derogatory, but really isn’t. It is just a category of therapy that is distinct from someone seen with a clear expectation of an ending. All of these folks would have started with a few sessions when they were in hospital for a surgery or other procedures, but they had a scary family history of cancer and felt under threat, or the adversity in their upbringing made it hard for them to trust anyone, and so the care for their physical illness was repeatedly compromised. The problem (is it a problem?) is that the work required to sort that out meant we got really into it; we delved deep into their stories. They risked sharing the shame and fear embedded in them. This can take years. Having someone to speak to, someone who saw their potential and capacity, was a lifeline, a tie that bound. Anyway, I am given to compromise, so patients and I often agreed to longer stretches between appointments and juggled times to keep going. It’s been working, imperfectly but well enough, for quite a while.
But now I am approaching classic retirement age. Do I do as my colleagues did and act as if I won’t get older, and at some point quit or die? I’m pretty sure that spending some able-bodied senior years showing my grandkids hermit crabs is a great option, and not one to perpetually postpone. I’ve tidied up my office, but what do I do with these people with whom I have longstanding intimate relationships of sorts, who despite our efforts, may not have anyone else available to them?
My answer is that I take on the ending with them, right now, and without obfuscation. We need to speak of this together. That’s the way to ensure they don’t feel overlooked, without value, like something left in a dead person’s basement. That one seminar didn’t teach me how to do this, but now that I’ve decided I’m going to stop doing this kind of psychotherapy sometime in the next few years, it feels like bullshit to go through sessions as if I am always going to be here. We can work together to use the trust we’ve forged to help them with another tough life event. If we don’t, it will be up to some stranger to help them. That feels like abandonment to me, and given how prevalent abandonment figures in the narrative of these folks, it doesn’t seem like something to risk repeating.
How’s it going, you ask? So far, mixed at best. The first person I told was gracious and congratulated me on getting through years of doing this work. They spoke of the benefit they received with deep feeling. I was encouraged, as they were not someone who had started their cancer treatment with trust. This was the “farewell tour” version of my plan. The second person took it as me punishing them for something that had happened at the start of the session, and the third person was just completely pissed off. She condemned me then, and still. In fairness, I blurted it out because I thought it fit into an unexpected discussion about endings. I ambushed her, and her rage is at least as much about my inconsideration in doing that as the fact of my leaving. But because I’ve raised it now, we have over a year to try and understand the meaning of it for her.
Acknowledging endings, and reflecting on what it means, on what is in our control and what isn’t, is a difficult but good thing to do. For a lifer, it means giving up a relationship that has been a central part of how they have managed to cope with adversity for years. It works best if they can resist filing it away as yet another abandonment or a case of someone putting their own needs first, and to see it from both sides. Gratitude helps, for both of us. The alternative is pretending, like sticking a Band-Aid to the back of a China plate and acting as if it can be used. It may look okay on the shelf, but it doesn’t have any resilience. I’d rather not shy away from the uncertainty and loss of the ending, and to try to help one more time.
Footnotes
This article has been peer reviewed.
The individuals represented here are a composite of patients.
This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: https://creativecommons.org/licenses/by-nc-nd/4.0/