Reflections at a Palliative Care Unit

On February 20, 2002,¹ Charles von Gunten, MD, PhD, introduced Reverend J, a 75-year-old former hospital chaplain with widely metastatic adenocarcinoma, who sought respite in the inpatient palliative care unit of a university hospital for the last days of his life. The author described the various models of primary, secondary, and tertiary palliative care services and the overarching goals of all palliative care, which are to provide comfort and quality of life as death approaches. The interdisciplinary model of care used in this tertiary care inpatient unit offers nursing, pharmacy, chaplaincy, and medical services to provide comprehensive medical and spiritual assistance, as required, for the entire family. Each year the unit hosts a "Day of Remembering" at which families and friends of patients and the unit staff join together to mourn and celebrate their loved ones. The following remarks were delivered by a senior physician at the 2002 Day of Remembering, which was attended by Mrs J, for the third year in a row:

Over the past 3 years, our team has cared for more than 400 dying patients—and you, their loved ones.

We have noticed the almost universal desire to hold on—sometimes literally—to the one who is dying. But at some point this becomes impossible. The one who is dying is leaving us, and we must let him or her go.

The poet Mary Oliver wrote about this letting go:

Letting go is the fundamental challenge for those of us who are left behind. But the letting go raises in us the question, "What is there left to hold on to?" Four things, I think: faith, memory, love, and one another.

Many of our patients and families come to us with religious faith—faith in resurrection, faith in reincarnation, and the like. Others come with a different, nonreligious faith—faith simply that life does not end in death.

In January, some weeks after her daughter's death, a mother expressed her faith with this elegy:

We hold on to our faith, even in the face of death.

Bearing witness to the death of one we love is hard. We all live in the hope that we will wake, remember, and understand.

In November, Thomas's extended family spent their last few days together recalling the good times, pasting their many photographs into albums, remembering others in their family who had gone before. They realized, I think, that there are things locked in memory—and that, in the last days together, they could find the key to it. There was a special quality to the time they spent together—there was briefly no past and no future, but instead a real sense of being in the present moment, in the here and now.

We hold on to our memories of the one who has died.

In December, Jocelyn died, with her husband, daughter, and son keeping several days of constant vigil at her bedside.The novelist Thornton Wilder ended his book The Bridge of San Luis Rey this way:

Even memory is not necessary for love. There is a land of the living and a land of the dead and the bridge is love, the only survival, the only meaning.⁵

We hold on to our love for the one who dies.

The antidote to the disconnection of death is connection to one another—to family, friends, and loved ones, who might be called "the whole connection of the individual" who is dying.

One day in June, I walked into the unit to find 32 people— holding hands in a giant circle around a woman who was dying just days after giving birth to a little girl. I joined the circle. Before the chaplain said some prayers, each of the people in the circle spoke aloud. Many wept. In the middle of it all, there was a knock at the door and in came the pediatricians with the new baby, to join the circle.

We hold on to one another.