In his 1965 book, The Teaching of Reverence for Life, the nineteenth-century German-French polymath Albert Schweitzer (1875–1965) thematically suggests that, in the evening of life, we must all confront the deep and painful question of whether we have given everything we were able to, and been everything we might have been, to the persons we love most. For Schweitzer, passing this existential final exam—one that requires us to search the dark corners of our souls to root out and rectify our regrets—holds the skeleton key to the possibility of living our dying well.
On an unusually warm afternoon in early October, I met Raymond, a 67-year-old patient with acute myeloid leukemia, a particularly aggressive and lethal form of blood cancer. At the time of his admission, Raymond’s prognosis was grim: he had days to weeks to live. I was consulted by the inpatient hospice team to help assess Raymond’s decision making capacity and to address a variety of seemingly unusual requests he had been making over the past two days.
What felt like less than a second after my shadow appeared against his salmon-pink door frame, Raymond cut right to the chase: “Is there any way you can help me sell my car? It’s absolutely urgent. If you can’t, do you know someone who can?”
Hours earlier, Raymond demanded that his treating team enroll him in an experimental chemotherapy and radiation trial to “postpone” his terminal cancer, something for which he had not been, nor ever would be, a candidate. He insisted that his clinicians “do everything” to keep him alive—“not forever, but at least until the end of the month.” Raymond asked that his previous doses of palliative chemotherapy and radiation—interventions that he had not received in over a month—be restarted and doubled. His oncologists sensitively shared with him the unfortunate reality that doing so would only hasten his death rather than prolong his life. According to Raymond’s daytime nurse, it was then that he shifted his focus exclusively, even obsessively, on selling an old car in his driveway.
“I would be honored to brainstorm solutions with you,” I replied to Raymond’s anxiety-ridden, automotive-related request as I finally reached the foot of his bed, “but if you have five minutes, I would love to get to know you better first.” “I can manage five minutes,” he replied, “but there’s really nothing to know besides the fact that my time on earth is running out, which simply can’t happen yet.”
While Raymond had seen countless healthcare professionals during his current admission, it was readily evident that our team had not cracked the surface of what he really needed. “What are you struggling with most today?” I asked him, watching his face contort with confusion. “People usually ask me how I am, or how I am feeling,” he replied, “and the answer is ‘obviously not good, or else I wouldn’t be here.’ But nobody has asked me directly about what makes this all so hard.”
My five-minute request to better understand Raymond turned into a two hour conversation during which he walked me through the story of his remarkable life and his far more remarkable soulmate, Margaret, his spouse of 36 years, who had unexpectedly passed away in a motor vehicle accident less than a year earlier. “I’m a promise keeper, and above all a loving and devoted husband,” he shared with me. “I can’t possibly die before I know I did right by Margaret.”
As Raymond unpacked his love story, I noticed the unspoken reality that this promise-keeper had one last promise to keep, but what was it? Why had he not shared it explicitly? What, exactly, did it have to do with his treatment plan or, stranger still, his car? Was he being coerced or manipulated into something, or were these requests and desires truly volitional? Acutely aware that time was of the essence, I decided to ask Raymond a direct, if presumptive, question: “What promise to Margaret do you still have to keep?”
Raymond’s posture softened and tears slowly filled his blue-gray eyes. Lowering his head, he turned to me and exhaustedly whispered, in a quivering tone, “I’ve been too embarrassed to tell anyone about this. You want to know the truth about how irresponsible I am? Fine. I can’t believe I’m saying this out loud, but here it is: I haven’t been able to afford a gravestone for my wife’s cemetery plot, and I simply can’t rest in peace without making sure that she’s at rest first. Aren’t I awful?” Reaching across his ivory-colored bed and placing my hand on his, I assured him that he was anything but awful, that his secret was safe with me, and that I would help him do whatever it took to honor Margaret.
Over the next two days, my colleagues and I worked tirelessly with personal and professional connections to secure the money necessary to purchase Margaret’s gravestone. By the end of that week, the stone was etched and ready for placement at Margaret’s gravesite. I asked the cemetery staff to record and send Raymond a video of the stone being installed. Witnessing the joyful grief on Raymond’s face as he watched footage of his wife being properly honored is something none of us will soon forget.
Finally possessing tangible proof that he, following Schweitzer, had given everything he was able to, and been everything he could have been, for Margaret, Raymond passed away peacefully 17 hours after he kept the most important promise of his life.
My hope is that “Raymond’s Rule”—the careful, compassionate, and critical process by which we ask questions that matter morally when they matter most—serves as a constant reminder that the most pressing concerns patients face, particularly at the end of life, are not primarily biophysical, but biographical. A renewed focus on, and dedication to, the narrative identity of patients can help to ensure that, in the process of healing the body, we do not mistakenly break the heart.
Works Cited
Schweitzer, Albert. The Teaching of Reverence for Life. Holt, Rinehart and Winston, 1965.
Series Information
Notes from the Bedside: A Clinical Ethics and Health Humanities Case Series offers a first-person account of patient care issues that arise at the intersection of clinical ethics and health humanities.
Confidentiality Notice
Identifying information has been redacted and/or changed to ensure patient confidentiality. Verbal consent was obtained from the patient and/or family prior to the writing of this piece.
Featured Image
Credit: Olga Kaya Photography.
