Saying Goodbye

Rodger Charlton

Pract 2023;45:1-2

An unusual title for a paper. I was reminded of this challenge in a professional conversation with a colleague and that it is something which should be written about.

Family Physicians pride themselves in providing continuity of care and personal care. As a result they get to know their patients very well and for many they provide what is often referred to as ‘cradle to grave’ care.¹ They know not only the patient but their relatives and extended family and the many people they interact within the community that the doctor works and the patient lives.

There comes a point in some patients’ lives where one recognises that they have very likely a short time to live. Sometimes it is because of an acute onset life-threatening illness or perhaps a long-term condition where the person is reaching end of life. As a doctor one is reticent to voice the feeling or concern that this could well be the last time you see this person alive. Quite often it is precipitated by the need for a crisis or emergency admission to hospital which you know from experience the likelihood of the patient coming out again or being able to go back into their own home, rather than a care home, is minimal.

So often I have received notification that one of these patients has died. I am reminded each time that I wish I had had the courage or made the opportunity to say goodbye. For many doctors, the longer they stay working in primary care, the better they get to know their patients. For some there is often a transition where patients become more than patients and dare I say ‘friends’ or at least you become a trusted confidante. There has been and there will continue to be many debates as to whether patients should be called patients or service users or one of the many other proposed names such as clients. However, for many doctors there are some patients that they get to know so well, that an invisible boundary is crossed from patient to something more meaningful as acquaintance which I have described as ‘friends’ within a supportive ongoing professional relationship.

Saying goodbye is difficult to do in a formal or prescribed way. However, there must be a personal way that we are all able to do, in words that are right for us, and don’t unduly upset the patient or cause them any deterioration as a result, but rather an acknowledgement of this special professional relationship derived by providing personal continuity of care.

As part of saying goodbye one recalls the patient journey that they have been through and how they have bravely fought the situation. Also that it has been a privilege to care for that person and that you will continue to be there for them if you can. But, by being compassionately honest that the next hurdle in their life and care, will be difficult. One must avoid blunt speaking or a truth communicated in an uncaring way. There is a seminal paper written on this subject in the Annals of Internal Medicine in 1980, with the title; ‘Words as Scalpels’.² This latter situation must be avoided at all costs.

It is true to say that doctors, even though they will not necessarily admit it, will themselves go through a personal bereavement and one that will be even more difficult if they did not have the chance to say goodbye to such a patient.

In examining the literature this is more than a personal view, but actually it is one of those topics that has not been written about specifically in primary care. However, there are papers outside of primary care which allude to the subject and one specifically on it.

Massachusetts transplant surgeon Pauline W. Chen describes how many doctors are still uncomfortable saying goodbye when the end is near. “Death is difficult no matter who you are. For doctors, it's made even more difficult, because in some ways it symbolizes failure.” ³

Back et al4 offer guidelines for physicians about how to say goodbye to a hospital or clinic patient who is in the last phase of life. The paper states that the authors know of no medical literature that describes how a physician can say goodbye to a patient who will probably never make another visit to the clinic or hospital. The authors state that saying goodbye is an expert practice worth learning for the sake of the patient and the physician. However, medical school teaching is such that it advises you to keep a distance from patients and that getting too close can be dangerous emotionally and perhaps this editorial is a challenge to us all to try to break or at least to adjust this barrier.

This paper in the Annals of Internal Medicine makes many important points⁴:

• The longer the period of patient care doctor, the stronger the doctor's emotions and the closer the relationships and that saying goodbye, is a “healthy response for a doctor."
• Saying nothing leaves patients and families confused, perhaps abandoned. However, saying goodbye permits the relationship to have closure and the patient feeling valued.
• Similarly, this provides an opportunity for the patient to say thank you and the doctor may say how the experience has contributed to their learning to be able to help others.

As with all such situations the authors recommend that doctors should:

• Choose an appropriate time and place that provides privacy.
• Make the goodbye an appreciation of the privilege that it has been to care for them and how the experience has been a very positive part of their work.
• Remind the patient that you are still available if needed and that you will continue to think about them.

It is important to follow up patients until the end and after a patient's death to try and phone a family member to give appropriate your condolences. This brings final closure and is a kind of a healing. All of this emphasises the importance of compassion and caring which is just as important as striving for a cure and this will hopefully bring comfort to the family. There is no reason why a doctor should not attend a funeral if they wish to as part of the last goodbye.

As the editorial started, it is important not to miss the opportunity to say goodbye and it should be planned in advance where it is practically possible and so bring an end to the consultations. Relatives will likewise be facing the same dilemma.⁵

In a personal view in the British Medical Journal Clark writes; “We know that patients wish for their financial, emotional, and spiritual needs to be addressed, and for a chance to say goodbye, is hardly the stuff of fancy medical technology.” ⁶

When one recognises that a patient may have very likely a short time to live, it will be a time and an opportunity for us individually to consider how we can compassionately say goodbye.

References