Chapter 30: Saying Goodbye

Over the years, I have said goodbye too many times. It has never been easy. At times I wondered whether saying goodbye meant I would never be happy again. Experience has taught me otherwise. Sometimes I have given a final goodbye without even knowing it. At other times it has been long and protracted. And one time, if you can believe it, I experienced a goodbye that was quiet and gentle, one that brought with it an unexpected sweetness.

In my life, I have experienced all of these. And I know that in time, I will say goodbye again. Time can ease the sadness of a final goodbye. Over time, what returns for me is the memory of the joy the person who left brought into my life.

And part of saying goodbye is recognizing what true love really is.

Medical Training

As a medical student, and even more so as a surgical resident, we learned medical skills, but we also learned to distance our emotions. During those ten years of training, I felt a natural bond to patients. I would see them daily while they were in the hospital, and even if I had only a small role in their care, I felt personal joy when they left the hospital. But sometimes I was involved in the care of patients who suffered and ultimately passed away. Sometimes I learned about their deaths after I had finished a rotation or after they were transferred to another medical team. At other times, they were on my service, and my team and I were either present at the time of death or learned of it early in the morning when we returned from our homes. There was sadness, but over time it was set aside so that we could continue to work. As physicians, we are trained to say goodbye professionally. We tell ourselves that this is different.

When I went into urology practice, my relationship with patients changed. Yes, in surgery there are many patients we see only for a single hospital stay. But urologists often care for patients over many years, men with prostate cancer, bladder cancer, kidney stones. Over time, I came to feel that these people were part of my extended family. That alone was reason enough to get up and go to work each day, and to return to the emergency room or the operating room late at night.

But over decades of working with people, there is inevitably death. It was uncommon for me to have a patient die while I was actively caring for them. More often, I learned of their deaths later, from other physicians, from family members, or occasionally from reading an obituary. Whether I had been closely involved in their care or simply heard the news, there was always a sense of loss. From my training, I learned to keep that loss muted in order to continue working. I was trained to remember my patients quietly, and to say goodbye on my own.

In the final eight months of my practice, I chose to do something different. I said goodbye in person to each patient I saw in the office. It was emotionally difficult for me, and likely for my patients, many of whom I had come to think of as family. At times, it felt as if I were saying goodbye in anticipation of my own death. Still, it felt far more important than a letter.

I might have expected that my ability to go on working effectively after a patient’s death would help me in my private life. But as I learned, death and saying goodbye within a family, or among very close friends who are not patients, is a different beast.

Cookie

I remember my mother, Cookie, during her last days. For most of my life, she was a dynamic, smart woman who did not take grief from anyone. I never met a person she could not stand up to. When I was in public elementary school, she demanded that my entire class be transferred to another teacher because she did not respect the one we were assigned for the upcoming year. A single discussion with the principal took care of that. You can imagine the butting of heads between my mother and her son. By the age of fourteen, I was quite sure I understood how the world worked, despite having very little experience. And yet, we both knew we loved each other.

Unfortunately, she developed breast cancer. She underwent a mastectomy and multiple rounds of chemotherapy over thirteen years. Eventually, the cancer metastasized to her bones. My father took care of her at home while still working, giving her pain medication injections until the pain became unmanageable. She was then brought to the hospital for her final days.

All four of us came to see her then. I was living and working in Seattle and had only a short time to visit her in New Jersey. It was difficult to see my mother, the strong and vibrant woman she had always been, lying in bed and at times incoherent. She who once could out talk anyone now spoke in a dreamlike way, often to herself, conversations that were difficult, if not impossible, tofollow. What I have recognized is that I was saying goodbye even while she was still breathing. That was difficult. I had no role in her medical care. I was simply her son.

On the day I was called about my mother’s death, I was scheduled to perform an urgent kidney transplant. I was asked if I wanted another surgeon to do the operation, but I felt I needed to do what I had committed to do. It gave me something clear to do at a moment when I had already said goodbye. After my mother died, I did what I knew how to do. I worked more. Looking back, I think it was my way of keeping my sadness at a manageable distance.

And when she passed away, I was on the other coast, but I knew there was nothing more I could have said to her in a goodbye. The only thing left was to say a final goodbye to myself.

Life goes on, and for me, if I want it to stop, it simply passes by. And not long after my mother died, I met Penny.

Penny

I met my late wife, Penny, a year after my mother had passed away. I was thirty six years old, early in my urologic practice, and trying to make a name for myself. She was an internist giving an early morning lecture on death and dying, and the role of the physician. I was immediately drawn to her because we shared similar feelings about this difficult and emotional topic. I introduced myself, asked her to coffee, and over time we saw each other often, became close, and married. As with my mother, she was a very smart and dynamic woman.

Eighteen months after our second child was born, she suddenly developed a severe headache and was admitted to the ICU with acute meningitis. She recovered, but over time it became clear that something was wrong. She had recurrent infections and repeated hospitalizations, without a clear explanation. Five years later, she developed a lump over her collarbone. A biopsy showed Non-Hodgkin’s lymphoma. In retrospect, it helped explain the years of illness.

She was treated with multiple courses of chemotherapy and experimental radiation given intravenously, but nothing stopped the disease. Because I was a physician, I was able to give her medications at home, much as my father had done for my mother. Eventually, though, her illness progressed to the point that she had to be hospitalized with a large abdominal mass. She remained in the hospital for three months. At times, I was able to take her outside in a wheelchair to briefly feel the sun. It was heartbreaking to see her cry when I told her that we needed to go back inside.

By then, we had accepted that this disease would end her life. We still hoped she might be able to leave the hospital for some time. Her oncologist felt that when all else failed, the mass might be temporarily controlled with standard radiation. As he said, “The mass will melt away with radiation.”

Unfortunately, science and disease do not always go hand in hand, and the tumor slowly worsened.

There was one occasion when I was able to take her home for a few hours. The house was in the middle of a remodel she had wanted and helped plan, work that had begun after she was admitted to the hospital. I wanted her to see what had been done. From the bedroom deck, she could now see Puget Sound. We stayed only a short time. And once again, the hardest part was returning to the hospital.

Penny’s mother came out to help with our two girls. Once, with sadness in her eyes, she said to me, “A child is not supposed to die before the parent.”

I was with her for most of her last three months. During the final five days of her life, I stayed in her room twenty four hours a day. I slept on an inflatable mattress that kept deflating about every three hours, which gave me the opportunity to check on her. The radiation had taken most of her energy, and for days she was unable to talk. On the third day, I asked her if it was time. She nodded yes, and we stopped all of the medications keeping her alive. Just being able to ask the question was difficult, but it had to be done. It was the same wish she had spoken about when she gave that first lecture when we met. And it was with that question that I truly said the final goodbye.

She slept, and there was no need to arouse her. After two days, I felt the need to leave the room for fifteen minutes. I went downstairs to the doctors’ lounge and got a cup of coffee. When I returned, I found that she had passed away.

Even though she had been sleeping, or in a coma, for two days, I felt an emptiness knowing she was alone for her final breath. And then I had to drive to my children’s elementary school to take them to the beach and let them know of their mother’s passing.

Afterwards I was crushed emotionally and exhausted. I had to comfort and raise our two young girls, each with their own terrible loss, and I put my own grief off. With time, I slowly reentered the world I had stepped away from. I knew that I had done what I could, and that her disease could not have been stopped. The sadness remained, but it eased with time. I came to think of it as a fog, with a little more sunlight showing through each day.

“There is a silence where no words reach. There is a presence beyond silence.” Annie Dillard

Jerry

And there was still one final goodbye, at least for this story.

When I finished my residency, I joined my first partner in urologic practice, Jerry. He was fifteen years my senior and had a small but thriving practice. More importantly, we quickly realized that we shared a similar outlook on life. He was a mountain man and skier who had learned how to sail. I was a beach boy and sailor who was learning about mountains. We enjoyed each other’s easy, positive joking manner. It was a pleasure to operate with him. We became a team. We rarely had to talk in the operating room. We knew what the other was thinking and about to do.

I was there for him when he went through his divorce and later celebrated his new marriage to Vicki. And although he was retired by then, he was there for me as Penny became ill, encouraging me through humor when I eventually began to date again.

Vicki and he moved to Montana, and for years I didn’t see him. Still, I always knew that if we did meet again, it would feel as if we had last seen each other only a week before. Then Vicki wrote to tell me that he had dementia. It was hard for me to grasp that the person I had worked with for decades, the person with whom I shared the same mental space, was losing exactly that. As things progressed, Vicki told me they would be traveling to Seattle. I asked if I might see him, and after some thought, she said yes.

I remember watching them enter the restaurant. Physically, he looked much the same, but there was a vacant look in his eyes. Vicki looked at me, then at him, and said, “Look, it’s T.C. (my nickname at the time)” Suddenly he brightened. With a wide smile, he said hello. For the next hour, we talked about the years we had worked together and the fun we had shared. When it was time to leave, Vicki gently let me know. As they walked away, I watched the vacant look return. I knew he would not remember our conversation. If he had turned around and come back five minutes later, he would have needed to be reintroduced. It was a bittersweet way to say goodbye to my partner and a very close friend.

A month or so later, my cell phone rang with an unknown number. I could see it was from Montana. I answered cautiously, and when his daughter introduced herself, I knew what she was going to say.

On Saying Goodbye

Saying goodbye after a long, slow downhill road is different from a sudden death, such as a heart attack or car accident. With long term illness, there is time to process what is coming and to slowly say goodbye. With sudden death, there is usually no such time. And yet, the similarity between the two remains the connection. Is there really much difference between saying goodbye to someone who has lost their cognition but still has a beating heart, and someone who loses both at the same time?

Death raises spiritual questions, and everyone has their own beliefs. For me, the question has been less about death itself and more about saying goodbye.

After Penny’s death, my friend Marsha, who is now demented, gave me this poem. It helped me think about goodbye, and about the sadness that comes with it:

Passing is nothing. I have only slipped away into the next room. I am I, and you are you. Whatever we were to each other, that we are still.

Call me by my old familiar name. Speak to me in the easy way which you always used. Put no difference into your tone. Wear no forced air of solemnity or sorrow.

Laugh as we always laughed at the little jokes that we enjoyed together. Play, smile, think of me, pray for me. Let my name be ever the household word that it always was. Let it be spoken without effect, without the trace of a shadow on it.

Life means all that it ever meant. It is the same as it ever was. There is absolute and unbroken continuity.

Why should I be out of mind because I am out of sight? I am but waiting for you, for an interval, somewhere very near, Just around the corner.

All is well.

— St. Augustine (354–430 AD)

For Myself

The irony of my being a Urologist who took care of men with prostate cancer and facing prostate cancer as a potential terminal disease is not lost on me.

How do I feel about my own saying goodbye to those I love, and who love me? I feel lucky. I have been given time to look back at my life, to give thanks, to offer apologies where they were needed, and to tell people that I love them. Those who love me have been given time as well.

For me, saying thank you, asking for forgiveness, giving it, and saying I love you has been freeing.