Dear Saras, It’s been close to a decade since we first met. Has it really been that long? It’s
surely long enough for me to become someone quite different from the person
who first beckoned you into the consultation room. But not long enough to forget
you.
I still remember the hand-knotted thread fringes of your blue shawl. You kept
your eyes on the floor, while your fingers found a knot in the fringe that had
come loose. I asked if there was anything you were worried about. Then you
looked at me and said, “I’m scared I’ll die in my sleep… and no one will know.”
I was barely a few months into palliative care then, trying to look as though I
knew what I was doing. You were a teacher, close to retirement, newly diagnosed
with metastatic lung cancer. The referral letter was brief. Its last line read: “No
options for further curative treatment. Referring to you for palliative care input.”
There was nothing brief about you, though.
Your words caught me off guard for two reasons. Most patients who came to us
arrived with someone beside them. You came alone, and went home to an empty
house. Your only son lived in Sydney. You spoke often, but visits were rare. And
you already knew you’d die. What you wanted to know was whether anyone
would notice.
I fell back on my training. Talked about increasing support as your illness
progressed. Explained how the team would remain involved, that you’d be cared
for. It was a good answer. It wasn’t the answer you were looking for. You
listened, then gave a knowing smile; the kind a teacher gives a student who’s
trying and not quite getting there. Placing your hand on mine, you said, “There’s
no easy answer to this, is there?” You paused. “But thank you for asking. Nobody
else has.”
I’ve wondered about that moment many times. I hadn’t solved your worries or
removed your fears. I hardly knew what to say. So why did you thank me?
Maybe you were grateful that, for a few minutes, someone had been willing to sit
with the fear you had named.
I understand better now, after a decade of this work. Patients rarely bring their
deepest fears at the beginning. They ask about the pain, the poor appetite, the
bad nights, because surely the doctor can help with these. There are other
questions too, unspoken: Will I become a burden? What happens when I can no
longer be the person I used to be? And, beneath it all, will I be alone at the end?
You taught me to wait for these, Saras, even when the waiting is long.I read
Richard Osman’s The Thursday Murder Club years later and thought of
you again. In it, residents of a retirement community give each other a missed
call at the same time every morning, a small ritual that says “I’m still here.” If
the call doesn’t come, someone comes looking. I recognized it right away as what
you’d been asking for, all those years ago: to know that if you ever stopped
answering, someone would notice.
I know so much more now than I did then, Saras. I can see the fear behind a
question even when a patient doesn’t say it aloud. Yet nobody has written a
protocol for the fear of dying alone. No algorithm for feeling forgotten. There is
only the question, asked and then left open. “What worries you the most?” “What
would you like to avoid, if you could?” And then the harder part: staying,
whether the answer comes quickly, slowly, or not at all.
I’ve often wondered what happened to you after you left that room. Did you fear
less? Did someone sit at your bedside when you needed them? I don’t know. We
enter our patients’ lives for a short while. We listen to their stories, adjust their
medications, and make our plans. Then, one day they’re gone, and we move on to
the next. Occasionally, someone stays long enough to make a difference.
You stayed.
You were one of the first to teach me that dying isn’t only the moment life ends.
It’s also the days and weeks before, when the losses arrive one at a time and the
roles disappear with them. The future keeps shrinking too. Beneath it, the
deepest fear of all: that no one would notice when you were gone.
I wish I could meet you again, Saras, and have that conversation differently. I’d
sit beside you and resist the urge to fill the silence. When you told me you were
scared you might die in your sleep and no one would know, I’d say only, “That
sounds frightening.”
And then I’d stay.
I still couldn’t give you certainty. I wouldn’t offer reassurance I don’t have. But I
would stay.
I thought I was the doctor and you were my patient, that my task was to have
the answers. I was wrong about that. You were the teacher. And I’m still your
student.
Still learning.
Your student,
Ruben
Dr Ruben Vighnesvaran is based at the Palliative Care Unit, Raja Permaisuri Bainun Hospital in Ipoh, Malaysia. He cares for patients with advanced illness and supports families through difficult decisions at the end of life. He writes reflectively about these encounters, sharing his work in his Facebook page, Always Something More-Reflections in Palliative Care (https://www.facebook.com/alwaysomethingmore). He can be reached at rubenvighnesvaran@gmail.com.
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