Goodbye?

I left work early, determined to visit my dying patient and check in before the weekend. Being Friday evening, the traffic was snarly, but I braved the morass and made it there safely.

Asleep in bed, "A." was curled in the fetal position, turned towards the wall, the hum of the pneumatic mattress and oxygen tank providing ambient white noise. Her daughter sat with me on the adjacent bed and we talked of A's life, her history, their relationship, family. She showed me some photo albums and I beheld images of A's more distant past which had been mostly a mystery to me. I always know that a larger life and history exists behind and within every patient: childhood, adolescence, family, travel, work and career---but those stories do not always enter into the ongoing conversation, frequently lost in the shuffle of health problems and medical care. Nonetheless, these details always help to flesh out one's portrait of the individual and are infinitely enlightening.

After some time, "A" awoke, and it seemed to take her a few minutes to register who I was. The change from three days ago was striking. She seemed wasted, thin ("cachectic" in medical terminology), and disoriented. She sat on the edge of the bed with our help, and made efforts to stand, which she did with my assistance. When I inquired where she wanted to go, she had nothing to say, so I invited her to dance, and we stood there, almost motionless, my arms around her, her right hand hooked in my belt, her left hand holding my right hand. Her daughter stood by, saying "Baile, mama!", "Dance, momma!". The excitement over, we sat on the big bed which sits just adjacent to the hospital bed, and "A" leaned against me as I held her upright, my arm around her thin shoulders. I said "I love you" in Spanish, and then in heavily accented English (the way she would say it, the "v" in love more like two "F's", sounding more like "luff"). She said "I luff you too" in her gutteral and congested voice which now emanates from her tightened throat. It was a poignant moment, and then the energy began to shift as I prepared to leave for home.

A's daughter asked me about A's fluid intake, and I advised her to keep it as minimal as possible in order to keep her lungs from filling up with fluid. I explained how A's kidneys are shutting down, producing little, if any, urine, and her daughter confirmed that A's urine output in the last 24 hours had been scant, and quite concentrated, a sure sign that her bodily processes are waning. I suggested popsicles as a nice treat and source of fluid and fructose, and told her how she can make her own or buy some at the store. The weight of A's small frame was pressed against my side.

Taking my leave once again, I said goodbye, again not knowing if this was the final goodbye, or just another moment of letting go, preparing for the real thing. When A's daughter had been out of the room, I had told A that she was free to go when she felt the time was right, that there was nothing to fear, that she was loved and cared for, and that her family would be OK after her departure. I remembered the last time I had told a patient that several months ago, and he had died within thirty minutes. I think A may last through the weekend, but I wanted her to know that she could consider leaving her body when she felt it was apropriate and right, and I know that my word holds great sway for her. Her vacant stare could not convey the deeper comprehension that I know she was experiencing in that moment.

These goodbyes are not just that---they are also hellos to the next incarnation, the next permutation. We practice and practice all our lives, letting go of possessions, people, places, experiences, ideas, concepts, delusions, desires. "A" is about to let go of the greatest anchor to the physical world---her 69-year-old body---and she can do so with peace and equanimity. I wish her well these next few days as she continues her process of release, and if I do not see her again in this life, I can bless her on her journey with a clear conscience and knowledge that our souls shared a connection that is greater than the sum of our physical selves. Those connections are eternal and incorporeal, yet no less real than the shaking of hands, the warmth of fleshly contact. There is nothing more satisfying than true connection with another. Blessings on you, A, as this physical journey draws to its natural close. To paraphrase Elizabeth Kubler-Ross, we live until we say goodbye.