Last impressions: Writing a note following a patient's death

First impressions are lasting. The way we greet a patient sets the tone of our relationship. I like to think that each time I greet a patient at the door with a smile, I put her at ease. And I like to think that when I tell her to "take good care" as she leaves my office, she understands that I truly mean those words.

We greet and leave patients every day. But what about the farewells to the patients who will never come back, the patients who have died, and to whom we'll never have a chance to give a final farewell? Early in my practice, I recognized that I needed a way to say goodbye to these patients.

Before my present position, I ran a solo private practice in a small Cape Cod town, where I was just as apt to see a patient at the grocery store as I was in the office. Like many internists in small towns, mine was a "family practice." I took care of husbands and wives, adult children and parents, brothers and sisters, and in-laws and ex-laws.

One of my first patients was Anne Marie, a vibrant 48-year-old mother of two who appeared to have it all. She was tall and slender, with long black hair, and the kind of woman whose age gilded her beauty.

She had a handsome and loving husband, Peter, two gorgeous children, and even a devoted mother-in-law who thought the world of her. She was active in our community, where she was well-liked and respected.

Soon after meeting Anne Marie, it was obvious to me that she was a very special human being. One by one, she sent her whole family to see me, and I was happy to assume the role of their family doctor.

Only a year after I met her, and a few weeks after her daughter's wedding, we found a mass on Anne Marie's chest x-ray. She faced her diagnosis bravely, and undertook chemotherapy in the manner she greeted every challenge in her life-with grace and dignity.

She lost her luxurious black hair, her strength, and appetite, but she never lost her beauty or spirit. She wrapped her head in colorful silk scarves; she covered her pallor with artful make-up, and kept a smile on her face that convinced all but the few of us who knew her secret that she was as healthy as ever. And as always, she brightened up any room she walked into, including my office.

Her tumor didn't respond to treatment, and over the course of a few short months, Anne Marie became too weak to leave her home. Her friends and family gathered around her, feeling as supported by her as she did by each of them.

I visited her several times. She greeted me with a warm smile every time I entered her room, though she must have known I had nothing but my presence to offer her. Each time I left, I wondered if I'd see her again, until the morning the hospice nurse called to tell me Anne Marie had died.

I called Peter and spoke with him briefly, expressing my condolences, and my gratitude for having had the chance to share in her care. She died too soon, we told each other. We lost her too soon.

When I hung up the phone and took her chart out of my file rack, I realized I needed some way to say goodbye to her.

SO MUCH TO SAY

As soon as I got home that night, I sat at my computer and wrote about Anne Marie. There was so much to say, I barely needed to think, and soon the words filled my screen. I wrote about her courage and resilience, and her grace and selflessness. I wrote about how I envied her sense of style, and about how I loved seeing the pride in her eyes when she spoke about her children. I wrote about all that she taught me in the short time that I knew her.

When I was done, I looked at the page and wondered what to do with it. It was too late to share it with her, but someone needed to read about Anne Marie. So I phrased the words into a letter and sent it to Peter, asking him to share it with his family. I felt better after I finished letter, and I hoped that it would help Anne Marie's family in some way.

A few weeks later, a colleague who was a close friend of Peter's told me he had read my letter. Peter was so touched by it, he shared it with everyone who came to see him after Anne Marie died. He kept it in his bureau drawer to read when he was feeling blue.